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I RECAP 


BLOOD  PRESSURE 

IN  G  ENER  AL  PR  AC  TICE 

BY 
PERCIV/VL  NICHOLSON,M.D. 


DICAL  BOOKS 

.  59thSt.,N.Y. 


'^<i1\ 


BLOOD    PRESSURE 

IN    GENERAL    PRACTICE 


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BLOOD    PRESSURE 

IN    GENERAL    PRACTICE 


BY 

PERCIVAL  NICHOLSON,  M.D. 


WITH  SEVEN  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

J.  B.  LIPPINCOTT  COMPANY 


COPTBIGHT,  1913,  BY 

J.  B.  LIPPINCOTT  COMPANY 


Printed  in  the  IMted  States  of  America 


w' 


i 


LIST  OF  ILLUSTRATIONS 

PAGE 

Auscultation  Method 8 

"Cook"  Sphygmomanometer 19 

"Stanton"  Sphygmomanometer 20 

"Janeway"  Sphygmomanometer     . 21 

"Roger"  Sphygmomanometer 24 

"  Nicholson  "  Syphgmomanometer 26 

Blood  Pressure  and  Temperature  Chart 42 


Intkoduction" 

In  issuing  this  volume  it  is  the  aim  of 
the  writer  to  furnish  to  the  general  prac- 
titioner and  surgeon  a  short  treatise  on 
blood-pressure  entirely  from  the  stand- 
point of  its  practical  significance  and  value. 

So  recent  is  the  whole  subject  of  blood- 
pressure,  its  significance,  the  means  of  de- 
termining it,  and  its  clinical  use,  and  so 
extensive  is  the  literature  on  blood-pres- 
sure published  mainly  in  journals  and 
magazine  articles,  that  the  busy  general 
practitioner  in  many  cases  has  not  been 
able  to  learn  the  methods  of  its  use  and 
application  in  clinical  medicine. 

With  this  in  mind  the  author  has  re- 
viewed the  literature  on  this  subject,  util- 
izing only  such  materials  as  he  deemed  of 
clinical  value,  avoiding  what  are  as  yet 
purely  theoretic  findings. 


vi  INTRODUCTION 

This  treatise  therefore  starts  with  the 
assumption  that  the  writer  is  dealing  with 
a  new  subject,  and  an  effort  has  been  made 
to  present  the  material  given  in  as  simple 
a  manner  as  possible. 

In  the  text  references  have  been  omitted, 
but  at  the  end  a  number  will  be  found  for 
those  desiring  to  study  the  subject  further. 

The  entire  subject  has  been  expressed  as 
concisely  as  possible,  and  to  some  it  may 
seem  dogmatically  treated  and  much  ma- 
terial to  have  been  omitted ;  but  the  author, 
in  extenuation,  wishes  to  state  that  this  is 
not  intended  to  be  an  exhaustive  treatise 
on  blood-pressure,  but  a  simple  exposition 
of  the  subject  easily  grasped  and  from  a 
clinical  standpoint. 

To  facilitate  ready  reference  the  dis- 
eases with  changes  in  blood-pressure  have 
been  arranged  in  alphabetical  order,  un- 
der the  general  headings  of  hypertension 
and  hypotension. 

If  this  simple  volume  shall  aid  the  gen- 
eral practitioner  to  a  better  understanding 
of  the  methods  of  determining  the  princi- 


INTRODUCTION  vii 

pies  and  some  of  the  practical  applications 
of  blood-pressure  determinations  its  mis- 
sion will  have  been  fulfilled. 

I  wish  to  express  thanks  to  Dr.  Wendell 
Reber  for  his  kindness  in  reviewing  the 
section  on  the  diseases  of  the  eye,  making 
this  section  as  condensed  as  possible,  but 
at  the  same  time  giving  all  the  essentials 
for  the  general  practitioner. 

Peecival  Nicholson 
Aedmore,  Pa. 


CONTENTS 

PAGB 

Inteoduction    y 

CHAPTER   I 

General  Consideration  and  Technique. 

Historical   review    1 

Importance  of  blood  pressure,  and  conditions 

to  which   it   applies 4 

Definition   of  blood  pressure 7 

Methods  of  measuring  blood  pressure: 

(1)  Palpation    8 

(2)  Auscultation     9 

Auscultatory     blood     pressure,     sounds,     and 

phases    11 

Auscultation  method,  on  what  based 13 

The  inertia  of  mercury,  and  the  relation  of 
the  oscillation  of  the  column  to  the  accuracy 
of  the  readings 14 


CHAPTER   n 

Blood  Pressure  Instruments. 

Choice   of   an  instrument 17 

Instruments :     18 

(1)  Mercurial. 

(2)  Those  using  other  fluid  media. 

(3)  Aneroid,    spring-diaphragm,     or   dial 

ix 


X  CONTENTS 

FAGB 

Instruments    (Continued)  : 

(1)  Mercurial     18 

(a)  Reservoir    type    19 

Examples      described,      ^'Cook" 

and  *' Stanton.'' 
Summary. 

(b)  U-tube     21 

Example  described,  ' '  Janeway. ' ' 
Summary. 

(c)  Closed  tube  mercurial 22 

Summary. 

(2)  Instruments     using    fluid    media    other 

than  mercury   23 

(3)  Aneroid,   spring-diaphragm,   or   dial  in- 

struments       23 

Discussion  of. 

Nicholson  apparatus  26 

Description  of   27 

CHAPTER    III 

Basic  Factors  on  Which  Blood  Pressure 
Depends,  Diastolic  and  Pulse  Pressure,  and 
Normal  Readings. 

Main  factors    28 

(1)  Cardiac  strength. 

(2)  Peripheral  resistance. 

(3)  Elasticity  of  vessel  walls. 

(4)  Volume  of  blood. 
Discussion  of. 

Pulse  and  diastolic  pressure 31 

Normal    range    of    pulse    pressure. 

Rule  to  estimate  diastolic  pressure   (Brun- 

ton). 
General  discussion  of. 
Importance   of   diastolic   and   pulse  pres- 
sure. 


CONTENTS  xi 

PAGE 

Normal  blood  pressure  readings 37 

Adults. 
Children. 
Low  limit. 

CHAPTER    IV 

Physiological   Variations   in    Blood   Pressure. 

Location  of  cuff 40 

Position    of   patient 40 

Meals    41 

Sleep    41 

Exercise   41 

Nervous   and   mental   stimuli 42 

Altitude   42 

Cardiac  cases. 

Phthisis. 

Summary     44 

Edema    45 

Asphyxia   45 

CHAPTER   V 
Hypertension. 

General  discussion  of 46 

Diseases  with  hypertension: 

Angiosclerosis 49 

Angina    pectoris    50 

Arteriosclerosis    51 

Autointoxication    56 

Diabetes    57 

Drugs :    57 

Adrenalin,  58;  cocain,  58;  camphor, 
58;  digitalis,  58;  normal  saline  so- 
lution, 59;  strychnia,  59;  atropin, 
60;   caffein,  60;  ergot 60 


xii  CONTENTS 

PAGE 

Diseases  with  hypertension  (Continued)  : 

Epilepsy,    idiopathic    60 

Exophthalmic  goiter   61 

Eye   diseases :    61 

Spasm  of  the  retinal  vessels,  63; 
cataract,  64;  chronic  interstitial 
nephritis  in  relation  to  the  eye,  65; 
glaucoma,  66 ;  retinal  hemorrhage . .       66 

Gout 67 

Heart   disease :    67 

Aortic  regurgitation,  67;  chronic  car- 
diac hypertrophy,  68;  cardiac 
valve  lesions  other  than  aortic, 
68;  heart  with  loss  of  compensa- 
tion, 68;  myocarditis,  69;  acute 
endocarditis,   71;    bradycardia,   71; 

cardiac  arrhythmia  71 

Increased  intracranial  tension :    71 

Apoplexy,  cerebral  thrombosis,  de- 
pressed fracture  of  skull,  fracture 
of  the  base,  jacksonian  epilepsy, 
intracranial   hemorrhage,   tumors 

(rapid  growing  cerebral) 71 

Nephritis :     73 

Chronic  interstitial,  74;  chronic  par- 
enchymatous, 75;  acute  nephritis, 
75;  uremia,  76. 

Obstetrics  and  eclampsia 76 

Plumbism    79 

Treatment  of  hypertension :    80 

Prophylactic,  general,  vasodilatation, 
and  other  measures 80 


CONTENTS  xiii 


CHAPTEE   VI 

HyPOTEN  SIGN.  PAGB 

Definition  and  general  consideration  of 95 

Diseases  with  hypotension: 

Acute  cardiac  conditions  and  peri- 
carditis           96 

Chronic    wasting    diseases:       Cancer, 

chronic  phthisis,   anemia 96 

Diseases  with  a  marked  loss  of  fluid: 
Cholera,  diarrhea,  dysentery,  and 
after  profuse  vomiting,  as  in  car- 
cinoma  of   the    stomach,   intestinal 

obstruction,   and   peritonitis 96 

Drugs :      Alcohol,    tobacco 97 

Hemorrhage    (extensive)    98 

Acute  infectious  diseases: 

Diphtheria,  99;  pneumonia,  99;  rheu- 
matism     (acute     articular),     102; 
scarlet    fever,    102;    typhoid   fever, 
102;   acute  infections  of  children,      105 
Neurological  conditions : 

Alcoholic  delirium,  105;  insomnia, 
105;  acute  mania,  106;  melancholia, 
106;  neurasthenia,  hysteria,  etc., 
106;  general  paresis,  106;  trifacial 

neuralgia   107 

Phthisis    107 

Shock    and    collapse 108 

Syphilis : 

Acute   109 

Tabes  dorsalis   109 

Treatment  of  hypotension 110 


xiv  CONTENTS 


CHAPTER   VII 

Surgery  and  Anesthesia.  page 

Ether    HI 

Nitrous   oxid    HI 

Chloroform    HI 

Spinal  anesthesia   (cocain) 112 

Operative  procedure   112 


CHAPTER   VIII 
Life  Insurance. 

Statistics     H7 

Importance  of  blood  pressure  readings  in 118 

Factors  to  be  considered 119 

Special  cases    122 

Bibliography  124 

Index 1^^ 


BLOOD  PRESSURE  IN  GENERAL 
PRACTICE 

CHAPTER   I 

GENERAL    CONSIDERATION    AND    TECHNIQUE 

HISTORICAL.— Going   a   little    into 
the  history  of  blood-pressure  de- 
termination we  find  it  dates  back 
to  1828,  when  Poiselli  introduced  the  first 
U-tube  mercurial  manometer. 

Shortly  after  Ludwig  devised  the  Kymo- 
graphion,  a  manometer  connected  directly 
to  an  open  artery,  and  recording  on  a  re- 
volving cylinder;  but  it  was  not  until 
1876  that  a  useful  apparatus  for  esti- 
mating blood-pressure  in  man  was  used 
by  Marey,  by  which  he  could  determine 
both  systolic  and  diastolic  blood-pressure. 
There  was,  however,  no  general  use 
of   blood-pressure   apparatus    until    some 

1 


2  BLOOD   PRESSURE 

eleven  years  later  (1887),  when  v.  Bosch 
bronght  forward  his  apparatus,  consist- 
ing of  a  small  rubber  bulb  filled  with 
water  and  connected  with  a  mercurial 
manometer;  the  bulb  being  pressed  upon 
the  radial  artery  until  the  pulse  was  just 
obliterated,  and  the  pressure  read  off  the 
manometer,  v.  Bosch  later  modified  his 
apparatus  by  using  an  aneroid  in  place  of 
the  mercurial  manometer. 

V.  Ptoin  further  substituted  on  the  v. 
Bosch  apparatus  air  in  place  of  water, 
which  was  a  great  advance,  but  both  in- 
struments have  a  large  possible  error, 
which  Tigerstedt  claims  has  reached  78 
mm. 

All  our  modern  apparatus  dates  from 
1896,  when  Riva-Rocci,  in  Italy,  used  a 
rubber  bag,  5  cm.  wide,  surrounded  by  an 
inelastic  material,  completely  encircling 
the  arm.  This  cuff  was  connected  by  rub- 
ber tubing  with  a  reservoir  of  mercury 
having  an  upright  capillary  tube,  along- 
side of  which  was  a  mm.  scale.  Air  was 
pumped  into   the   cuff,   compressing  the 


IN   GENERAL  PRACTICE  3 

brachial  artery  until  the  pulse  below  the 
band  was  obliterated,  and  then,  by  releas- 
ing the  air  slowly,  he  determined  when  the 
pulse  reappeared  and  thus  obtained  a  read- 
ing of  the  maximum  or  systolic  pressure, 
shown  by  the  column  of  mercury  in  the  ca- 
pillary tube. 

All  instruments  which  give  accurate 
readings  have  utilized  the  principle  of  the 
pneumatic  constricting  band,  except  that 
now  the  width  of  the  cuff  is  at  least  12 
cm.,  as  the  narrow  cuffs,  such  as  the  orig- 
inal Riva-Rocci,  give  too  high  readings. 
This  very  important  error  was  shown  by 
the  work  of  v.  Recklinghausen  to  be  due 
to  the  loss  of  pressure  in  compressing  the 
tissues,  and  that  it  could  be  eliminated  if  a 
cuff  from  12-15  cm.  wide  were  utilized. 
Dr.  T.  C.  Janeway  states  he  has  found  in 
high-tension  cases  a  5-cm.  cuff  to  register 
as  much  as  60  mm.  higher  than  a  12-cm. 
cuff. 

All  our  modern  blood-pressure  determi- 
nations, as  on  the  Riva-Rocci  instrument, 
are  recorded  as  the  pressure  measured  by 


4  BLOOD   PEESSUEE 

the  heiglit  of  a  column  of  mercury  of  so 
many  mm.,  or,  in  other  words,  mercury  is 
the  standard  on  which  blood-pressure  read- 
ings depend. 

The  Importance  of  Blood-pressure  and 
Conditions  to  Which  It  Applies.— The 
whole  subject  is  one  which  has  become 
prominent  from  a  practical  standpoint,  in 
this  country  in  about  the  last  eleven  years, 
though  it  had  its  beginnings  as  far  back 
as  1828  in  Europe. 

It  has  been,  however,  only  in  the  last  ^ve 
years  that  the  importance  of  accurate 
blood-pressure  readings  in  their  diagnos- 
tic, prognostic,  and  therapeutic  applica- 
tion to  general  medicine  has  begun  to  be 
appreciated,  and  their  value  realized  by 
the  general  practitioner. 

Blood-pressure  determinations  are  now 
of  so  well  recognized  value  in  medicine  and 
surgery,  that  one  of  the  important  ques- 
tions of  to-day  is  what  are  their  applica- 
tion and  meaning  in  special  conditions,  and 
how  reliable  are  they  when  other  means 
fail  us. 


IN   GENERAL  PRACTICE  5 

Dr.  T.  C.  Janeway  has  very  clearly  ex- 
pressed the  matter  in  a  recent  article, 
''When  Should  the  General  Practitioner 
Measure  Blood-pressure?" 

He  says,  in  substance,  it  should  be 
taken: 

(1)  In  the  first  examination  of  every  pa- 
tient. 

(2)  Occasionally  for  watching  the  prog- 
ress of  cardiovascular  disease  and  ne- 
phritis. 

(3)  Examination  for  certifying  to  the 
state  of  health :  in  life  insurance ;  in  appli- 
cants for  the  army,  navy,  police,  fire  de- 
partment, and  in  schoolboys  engaged  in 
athletics;  and  he  also  mentions  eclampsia 
and  diagnosis  in  conditions  with  abdominal 
pain. 

In  addition  Briggs  and  Cook  show 
blood-pressure  determinations  to  be  one  of 
the  most  important  aids  in  diagnosis  and 
treatment  of  eclampsia  and  cardio-renal 
disease,  and  their  undoubted  value,  in  ty- 
phoid fever,  in  medication  of  children;  in 
surgery  before,  during,  and  after  opera- 


6  BLOOD  PEESSUEE 

tive  procedures,  and  in  injuries  of  the 
head,  etc. 

In  a  paper  on  diagnosis  read  before  the 
Michigan  State  Medical  Association  Dr. 
Eichard  C.  Cabot  says:  *^The  next  pro- 
cedure, following  my  personal  routine,  is 
the  examination  of  blood-pressure.  That 
leads  me  to  say  something  about  the  value 
of  blood-pressure  in  physical  diagnosis.  If 
I  were  allowed  to  have  only  two  instru- 
ments of  precision  for  my  aid  in  physical 
diagnosis,  they  would  be  the  stethoscope 
and  the  blood-pressure  machine. 

**I  have  been  saved  from  wrong  diag- 
noses and  put  on  the  track  of  right  ones 
more  often  by  that  machine  than  anything 
else  I  know  of,  except  the  stethoscope. 
And  I  am  speaking  now,  as  I  spoke  all 
along,  by  the  check  of  the  autopsy. 

"I  regard  the  measurement  of  blood- 
pressure  as  the  most  important  of  all  the 
resources  that  have  been  added  to  our 
armamentarium  as  physicians,  in  the  last 
fifteen  years. 

**The  measurement  of  blood-pressure, 


IN   GENERAL   PRACTICE  7 

when  you  are  familiar  with  the  method, 
can  be  made  in  a  minute  and  a  half  per- 
fectly well.'' 

Blood-pressure  determinations  are  of 
value  to  the  specialist  in  eye  and  ear  con- 
ditions ;  in  fact,  there  is  no  branch  of  medi- 
cine in  which  blood-pressure  is  not  signifi- 
cant, and  often  an  aid  when  other  means 
of  diagnosis  have  not  been  sufficient. 

Definition.— By  blood-pressure  is  meant 
the  arterial  tension  or  pressure  of  the 
blood  in  the  vessels  within  which  it  is  con- 
tained. 

Systolic  and  Diastolic. — Blood-pressure 
is  divided  into  the  maximum  or  systolic 
pressure  and  the  minimum  or  diastolic. 
The  systolic  is  the  gTeatest  pressure  ex- 
erted and  takes  place  during  systole  of 
the  heart ;  the  diastolic  is  the  lowest  pres- 
sure, and  occurs  in  the  cardiac  cycle  just 
at  the  beginning  of  the  systole,  or  at  the 
end  of  the  diastole,  the  time  when  most  of 
the  blood  has  passed  on  through  the  ca- 
pillaries into  the  veins. 

Pulse  Peessuee. — From  these  we  obtain 


8  BLOOD   PRESSUEE 

^^ pulse  pressure/'  wMcli  is  the  difference 
between  the  diastolic  and  systolic  pres- 
sures. 

Mean  Peessuee. — Mean  pressure  is 
about  the  average  between  the  systolic  and 
diastolic  readings,  but  has  little  clinical 
value  and  is  seldom  used. 

Methods  of  Measuring  Blood-pressure.— 
The  apparatus  being  set  up  ready  to  op- 
erate the  pneumatic  cuff  is  adjusted 
snugly,  and  without  compression,  to  either 
the  arm  or  the  thigh,  usually  the  arm,  tak- 
ing care  that  the  cuff*  is  at  the  level  of  the 
heart.  The  cuff  is  then  inflated  until  the 
pulse  below  the  constriction  is  obliterated, 
which  is  determined  by  palpating  the  ar- 
tery. The  estimation  of  blood-pressure  is 
then  made  by  either  one  of  two  methods: 
(1)  The  old  or  Palpation  Method,  (2) 
The  new  or  Auscultation  Method,  de- 
scribed in  1905  by  Korotkow. 

Palpation  Method. — (a)  Systolic. — - 
After  obliterating  the  arterial  pulsation  in 
the  vessel  below  the  cuff,  slowly  release 
the  air  pressure,  allowing  the  mercury  to 


IN   GENERAL   PRACTICE         9 

fall  evenly,  and  note  the  height  of  the  col- 
umn when  the  pulsation  reappears  to  the 
palpating  finger.  This  gives  the  systolic 
or  maximum  pressure,  and  will  be  found 
easy  to  obtain  on  all  instruments. 

(b)  Diastolic. — After  taking  the  systolic 
pressure  allow  the  mercury  to  fall  slowly, 
and  note  the  varying  degrees  of  oscillation 
of  the  mercury  column.  Read  the  scale  at 
the  base  of  the  maximum  fluctuation  and 
it  gives  the  diastolic  pressure. 

Or  when  the  first  change  from  a  small  to 
a  full  bounding  pulse  is  noted  read  the 
height  of  the  mercury  column,  and  it  gives 
the  diastolic  pressure. 

Both  methods  of  determining  the  dias- 
tolic pressure  are  very  unreliable  and  not 
accurate  nor  practical  in  general  practice. 

AuscuLTATioiT  Method. — This  is  an  ac- 
curate method  for  both  systolic  and  dias- 
tolic determinations. — (a)  Systolic. — As 
in  the  palpation  method,  having  inflated 
the  cuff  until  the  pulse  is  obliterated, 
place  the  bell  of  an  ordinary  binaural 
stethoscope  over  the  artery  just  below  the 


10  BLOOD  PRESSURE 

cuff.  Now  release  the  air  pressure  slowly 
and  listen  with  the  stethoscope.  "When  the 
first  cardiac  beat  passes  the  constricting 
cuff  a  loud,  clear  thump  is  heard  and  the 
true  systolic  pressure  is  obtained  by  read- 
ing the  height  of  the  mercury  column. 

(b)  Diastolic. — ^In  taking  the  diastolic 
pressure  continue  to  release  the  air  and 
listen  over  the  artery.  The  thumping 
sound  is  followed  by  a  murmur,  and  then 
by  a  second  thumping  sound,  which  be- 
comes fainter  and  suddenly  disappears. 
At  the  time  the  second  thumping  sound 
becomes  fainter,  again  note  the  height  of 
the  mercury  column,  which  gives  the  true 
diastolic  pressure. 

This  last  auscultation  method  has  almost 
revolutionized  the  determination  of  hlood- 
pressure,  for  the  diastolic  pressure  can  he 
as  easily  and  accurately  determined  as 
systolic  pressure,  a  result  impossible  to 
attain  in  the  past,  there  being  such  a  large 
personal  element  in  obtaining  the  diastolic 
pressure  that  most  observers  did  not  at- 
tempt it. 


IN   GENEEAL   PRACTICE        11 

The  diastolic  and  pulse  pressure  (differ- 
ence between  systolic  and  diastolic)  are 
thu^  accurately  determined  hy  this  method, 
and  are  often  of  even  greater  importance 
than  the  systolic. 

Auscultatory  Blood-pressure,  Sounds 
and  Phases.— Placing  a  stethoscope  over 
the  brachial  artery  just  below  the  constrict- 
ing cuff  and  releasing  the  air  pressure 
slowly,  you  hear  five  distinct  phases  in 
most  all  cases. 

(1)  A  loud,  clear  thump  is  heard  as  the 
first  wave  of  blood  passes  the  constricting 
cuff,  which  gives  the  systolic  pressure  by 
reading  the  height  of  the  mercury  colunm. 

(2)  In  a  short  time  the  first  phase  is 
followed  by  a  murmur,  which  lasts  for  a 
variable  period,  and  constitutes  the  second 
phase. 

(3)  After  the  murmur  a  loud,  clear 
thump  is  again  heard,  constituting  the 
third  phase,  often  louder  than  the  first 
phase. 

(4)  Then  the  third  phase  passes  into  the 
fourth,  which  is   simply  a  duller  sound 


12  BLOOD   PRESSUEE 

similar  to  the  third  and  is  probably  pro- 
duced by  the  return  of  the  blood  vessel  to 
its  normal  caliber  as  the  air  pressure  is 
lowered. 

(5)  The  sounds  in  the  fourth  phase  grad- 
ually become  fainter  until  you  have  the 
fifth  phase  or  the  disappearance  of  all 
sound.  The  end  of  the  fourth  phase  or 
beginning  of  the  fifth  phase  gives  the  true 
diastolic  pressure. 

At  the  present  time  there  has  not  been 
enough  work  done  on  the  intensity  of  the 
sounds  of  the  various  phases  or  their  rela- 
tive lengths  in  mm.  of  mercury  to  give  any 
positive  findings,  though  much  suggestive 
work  has  been  done  along  this  line.  The 
intensity  of  the  sounds  of  the  third  phase 
being  considered  of  importance  in  deter- 
mining the  cardiac  strength,  a  loud  clear 
sound  indicating  a  strong  heart  and  vice 
versa. 

The  main  information  at  present  ob- 
tainable from  the  auscultation  method  is 
the  determination  of  accurate  systolic  and 
diastolic   pressures   and  from   them   the 


IN   GENERAL   PRACTICE        13 

pulse  pressure,  hy  the  simple  process  of 
subtraction,  e.  g. 

Systolic    160  mm.  Hg 

Diastolic    120  mm.  Hg 

Pulse  pressure   40  mm.  Hg 

Of  pulse  pressure  and  diastolic  pres- 
sures I  shall  have  more  to  say  later. 

Auscultation  Method,  on  What  Based. 
— In  the  auscultation  method  it  is  largely 
a  question  of  the  physics  of  fluids,  e.  g., 
the  artery  is  constricted  by  means  of  the 
pneumatic  cuff;  below  it  there  is  no  ar- 
terial flow,  and  the  vessel  walls  are  in  a 
semi-relaxed  condition.  The  air  pressure 
in  the  cuff  is  lowered  gradually  until  the 
heart  has  power  enough  to  drive  some 
blood  into  the  relaxed  vessel  beyond. 
The  sudden  flow  of  blood  into  the 
relaxed  vessel  sends  the  wall  into  vi- 
bration, and  a  loud,  clear  thump  is 
heard,  which  gives  the  systolic  pressure. 
In  making  the  diastolic  estimation  there 
again  is  a  physical  condition  of  a  fully  ex- 
panded artery  above  the  pneumatic  cuff, 


14  BLOOD  PRESSURE 

a  constriction  under  the  cuff,  and  an  en- 
largement below.  Fluid  passing  from  a 
large  tube  through  a  constriction  into  a 
large  opening  makes  a  murmur,  exactly 
what  takes  place,  and  when  the  caliber  of 
the  tube  is  uniform,  or,  in  other  words, 
when  the  diastolic  pressure  is  able  to  over- 
come the  constriction  of  the  cuff,  there  will 
be  no  longer  any  sound.  It  can  easily  he 
seen  that  it  makes  no  difference  whether 
the  mercury  column  records  each  pulsation 
of  the  heart  or  not,  but  that  it  shows  much 
more  easily  and  accurately  the  correct 
hlood-pressure  than  could  he  read  if  it 
were  fluctuating  very  actively. 

The  Inertia  of  Mercury  and  the  Relation 
of  the  Oscillation  of  the  Column  to  Ac- 
curacy of  Readings. — Here  I  wish  to  make 
clear  a  point  which  has  created  consider- 
able confusion  in  the  past,  the  relation  of 
the  inertia  of  the  mercury  column  to  the 
determination  of  the  diastolic  pressure, 
and  also  as  to  whether  it  is  of  importance 
for  the  column  of  mercury  to  fluctuate 
with  each  pulsation  of  the  heart.     Were 


IN   GENERAL  PRACTICE        15 

we  to  adhere  to  the  old  method  of  reading 
the  diastolic  pressure,  the  lowest  point  of 
the  maximnm  fluctuation,  the  mercurial  in- 
ertia might  be  of  slight  importance,  but 
from  a  practical  standpoint  it  is  of  little 
significance. 

When  we  use  the  auscultation  method 
for  determining  diastolic  readings,  a 
method  now  almost  universally  used,  on 
account  of  its  ease  and  accuracy,  the  lack 
of  fluctuation  of  the  mercury  has  abso- 
lutely no  disadvantage.  On  the  contrary, 
it  becomes  easier  to  obtain  the  true  'pres- 
sure reading,  ivhere  the  column  is  not  ac- 
tively oscillating,  as  is  the  needle  of  the 
aneroid. 

Confusion  has  been  brought  into  this 
subject  of  blood-pressure  due  to  the  er- 
roneous idea  having  been  advanced  that 
the  actual  fluctuation  of  the  mercury  col- 
imm,  or  needle  of  the  aneroid,  is  essen- 
tial, it  recording  each  pulsation  of  the 
heart. 

If  pulsations  are  to  be  recorded  it  is 
better  to  employ  a  sphygmograph  (where 


16  BLOOD   PEESSUEE 

the  pulsations  conld  be  preserved  and  in- 
terpreted, as  they  could  not  on  a  blood- 
pressure  apparatus),  but  for  the  determi- 
nation of  blood-pressure  the  sphygmoma- 
nometer should  be  used. 

To  illustrate  this,  let  us  recall  a  little 
problem  of  physics :  a  pump  forcing  water 
through  a  pipe  gives  an  intermittent  flow. 
Placing  an  air-dome  on  the  pipe  line 
makes  the  flow  continuous  beyond  the 
dome,  but  the  pressure  is  equal  on  both 
sides.  So  hlood-pressure  determination  is 
a  question  of  tUe  pressure  existent  in  the 
arterial  system,  not  of  the  pulsation  of  the 
heart. 


Fig.   1. — "Auscultation  method. 


IN   GENEEAL   PRACTICE        17 


CHAPTER   n 

BLOOD-PEESSUEE    INSTEUMENTS 

CHOICE    OF    AN    INSTEUMENT.- 
The  number  of  instruments  at  pres- 
ent   available    for    blood-pressure 
work  is  legion,  and  it  is  decidedly  confus- 
ing to  one  entering  this  field  to  select  a 
good  practical  instrument. 

In  Ms  book,  ^^A  Clinical  Study  of  Blood- 
pressure,"  Dr.  T.  C.  Janeway  gives  the 
following  ad^T-ce  on  the  choice  of  a  sphyg- 
momanometer : 

(1)  ^'  Manometer  must  be  of  such  construc- 

tion as  to  give  permanently  exact 

readings. 
No  metal  manometer  yet  invented  re- 
mains accurate,  hence  this  means  the  use 
of  a  properly  graduated  mercurial  one, 

(2)  Compressing    armlet    must    have    a 

width  of  at  least  12  cm. 


18  BLOOD   PEESSUEE 

(3)  Connections  must  be  practically  non- 

distensible  tubing. 

(4)  It  must  measure  both  systolic  and  di- 

astolic pressure. 

(5)  Its  application  must  be   simple,  and 

require  not  more  than  two  to  three 
minutes. 

(6)  It  must  be  at  once  substantial,  ligbt, 

and  compact,  so  that  it  may  be  easily 
and  safely  carried. 

(7)  It  must  not  be  too  costly." 
Instruments.— Every  apparatus  for  de- 
termining blood-pressure  belongs   in  one 
of  three  classes,  those  using: 

(1)  Mercury. 

(2)  Some  other  fluid  medium. 

(3)  The  aneroid,  spring  diaphragm  or 
dial. 

(1)  The  mercury  type  is  further  divided 
into: 
A.  Those  having  a  reservoir;  the 
mercury  rising  in  an  open  end 
capillary  tube  from  a  zero  point 
and  having  a  scale  graduated  in 
millimeters. 


Fig.  2. — Cooke's  modification  of  the  Riva-Rocci  sphygmomanometer,  showing  narrow  arm- 
band in  place,  with  cautery  bulb-inflator. 


IN   GENEKAL   PKACTICE        19 

B.  Those  employing  the  U  tube. 

C.  Those  having  a  short  straight  tube 

with  a  closed  end. 

Class  A. — To  this  class  belong  the  ^'Riva- 
Rocci,"  the  ^^Cook,"  the  ^' Stanton/^  and 
more  recently  the  ''Sands/'  a  copy  of  the 
"  Stanton. '^ 

I  shall  give  you  a  brief  description  of 
the  two  simpler  forms,  the  "Cook''  and  the 
"Stanton." 

The  "Cook"  seen  in  cut  No.  1  utilizes 
all  the  principles  of  the  original  Riva- 
Rocci  instrument,  consisting  of  a  constrict- 
ing pneumatic  cuif  connected  with  a  mer- 
curial manometer,  and  having  a  means  of 
inflation.  The  cuff  when  applied  over  the 
brachial  can  be  filled  with  air  until  the 
pulse  at  the  wrist  is  just  obliterated. 

This  is  a  fairly  accurate  instrument  for 
determining  systolic  readings,  but  not  hav- 
ing a  good  air  release  is  not  practical  in 
determining  diastolic  pressures.  It  is  in- 
accurate in  that  it  uses  a  5-cm.  cufp,  which 
gives  too  high  readings. 

Though  by  the  use  of  a  jointed  tube  it  is 


20  BLOOD   PEESSUKE 

fairly  compact,  the  mercury  is  easily 
spilled  and  the  instrument  fragile.  Its 
double  bulb  for  inflation  is  also  a  constant 
source  of  annoyance  from  blowouts. 

Now  turning  to  cut  No.  2  the  original 
**  Stanton '^  apparatus  is  seen,  a  reliable 
instrument,  but  no  longer  manufactured. 

(1)  It  was  a  large,  heavy  instrument, 
using  a  10-cm.  cuff,  which  gave  too  high 
readings. 

(2)  It  was  not  very  portable,  requiring 
to  be  taken  apart  and  set  up  when  used  in 
general  practice. 

(3)  It  was  difficult  not  to  lose  the  mer- 
cury. 

(4)  It  had  the  same  defect  as  the 
*'Cook''  apparatus  in  that  it  used  a  double 
rubber  bulb  for  inflation.  However,  it  was 
largely  adopted  and  gave  accurate  read- 
ings when  a  wide  cuff  was  used. 

All  the  instruments  of  this  class  have 
their  drawbacks  preventing  their  becom- 
ing practical  portable  instruments.  Some 
require  the  manipulation  of  screws  and 
washers;   some   are  large  and  heavy  to 


Fig.  3. — .Stanton's  sphygniomauonuMer,  showing  arrangement  of  parts,  with  cautery 

bulb-inflator. 


Fig.  4.- 


-Janeway  sphygmomanometer,  attached  to  arm,  showing  method  of  retention  of  cuff- 
arrangement  of  momanometer,  with  Politzer  bag  inflator. 


IN   GENERAL  PRACTICE        21 

transport;  in  all  the  loss  of  part  of  the 
mercury  cannot  be  prevented  and  the  dou- 
ble rubber  bulbs  are  constantly  getting  out 
of  order. 

They,  therefore,  are  not  instruments 
suitable  for  the  general  practitioner. 

Class  B. — The  U-tube  instruments. 

In  this  class  are  the  ^^  Janeway,''  *^  Mar- 
tin,'' ^^  Mercer,''  *^  Brown,"  *^Sahli," 
**  Faugh t,"  and  many  others. 

In  the  cut  you  can  see  the  ^'Janeway," 
which  is  one  of  the  earliest  and  best  known 
of  this  class. 

This  instrument  has  the  advantage  over 
many  others,  in  that  it  uses  an  accurate 
12-cm.  cuff,  and  hence  the  readings  are 
correct  on  most  of  the  instruments. 

(1)  But  in  order  to  carry  it,  the  end  of 
the  U-tube  has  to  be  closed  with  a  cork, 
which  is  often  forgotten  and  as  a  result 
the  mercury  is  spilled. 

(2)  The  mercury  often  escapes  from  the 
joint  made  on  the  long  arm  of  the  U 
tube. 

(3)  As  made  now,  there  is  a  wide  metal 


22  BLOOD   PRESSURE 

union  which  obstructs  the  reading  for  some 
30  mm.  in  the  middle  of  the  scale. 

(4)  Like  all  U-tube  instruments  the 
scale  has  to  be  condensed  one-half  to  al- 
low for  the  descent  of  one  column  while 
the  other  rises,  so  none  can  be  read  closer 
than  two  mm. 

As  glass  tubing  cannot  be  blown  of  uni- 
form caliber  there  is  often  a  swell  in  one 
limb  of  the  manometer  precluding  the  mer- 
cury from  rising  or  falling  equally  in  both 
sides  and  as  one  column  is  balanced 
against  the  other  any  error  is  multiplied 
by  two.  Two  instruments  recently  exam- 
ined were  found  to  vary  40  mm. 

Many  of  the  U-tube  instruments  are  too 
bulky  to  transport  and  the  others  which 
are  shorter,  using  a  jointed  tube,  have  been 
condemned  by  many  because  a  plug  must 
be  placed  in  the  end  of  the  tube  to  prevent 
the  spilling  of  the  mercury. 

Class  C, — In  order  to  attain  portability, 
a  greatly  desired  feature  in  blood-pressure 
apparatus,  several  instruments  have  been 
made  having  a  short  closed  tube  with  mer- 


IN   GENERAL   PRACTICE        23 

cury  working  against  the  inclosed  air, 
e.  g.,  ^* Hertz,'*  *^ Roger's  Simplex." 

These  have  failed  because:  (1)  The 
scales  have  necessarily  to  be  condensed, 
making  the  readings  gross,  and  further 
this  condensation  greatly  increases  any  er- 
ror. (2)  The  scales  have  to  be  specially 
standardized  by  comparison  with  a  mer- 
curial column  and,  being  fixed  on  the  glass, 
cannot  be  adjusted  to  allow  for  any  change 
in  the  compressibility  of  the  inclosed  air 
column,  which  varies  greatly  according  to 
moisture,  temperature,  and  climate. 

Type  2. — (Instruments  using  fluid  me- 
dium other  than  mercury). — These  instru- 
ments are  too  long  for  portability  where 
the  open  end  tube  is  used  or  where  the 
closed  end  tube,  e.  g.,  ^^Bendick  air-water 
apparatus."  They  have  all  the  disadvan- 
tages of  the  closed  end  mercurial  instru- 
ments. 

Type  3. — (The  aneroid,  spring  dia- 
phragm or  dial). — In  addition  there  are 
the  aneroids  or  spring  diaphragm  instru- 
ments, following  the  old  model  of  the  v. 


24  BLOOD   PEESSUEE 

Bosch  aj)paratus.  These,  while  convenient 
in  some  respects,  as  Dr.  Janeway  says: 
'*Need  to  be  standardized  frequently  by 
comparison  with  a  mercurial  manometer, 
which  is  irksome,  and  they  are  difficult  of 
repair. 

'^Depending,  as  they  do,  on  a  spring 
they  wear  out  and  are  not  dependable. ' ' 

Their  lack  of  dependability  is  clearly 
shown  by  Dr.  J.  W.  Fischer,  medical  di- 
rector of  the  Northwestern  Life  Insurance 
Company,  when  he  says  in  a  letter  to  his 
medical  examiners:  *^The  experience  of 
this  department  with  the  various  makes 
of  sphygmomanometers  has  convinced  us 
that  the  use  of  an  instrument  registering 
the  blood-pressure  with  a  mercurial  column 
is  preferable,  although  the  spring  or  dia- 
phragm instruments  are  satisfactory  if  oc- 
casionally checked  up  with  a  mercurial  in- 
strument. ' ' 

The  spring  aneroid,  so-called  dia- 
phragm, instruments  have  solved  the  por- 
tability problem,  but  have  added  many  in- 
accuracies, so  they  are  not  dependable. 


Fig.  o. — Roger's  sphygmomanometer  adjusted  to  aim,  showing  atomizer  bulb-inflator. 


IN   GENERAL  PRACTICE        25 

The  elasticity  of  a  solid  is  a  variable 
quantity  at  the  best.    So  in  the  aneroid  or 
dial  instruments   the   expansion  and  the 
contraction  lessen  the  elasticity  until  no 
dependence  can  be  placed  on  its  reaction. 
To  compensate  for  this  loss  of  elasticity 
the  manufacturers  make  the  dial  movable 
so  the  indicator  can  be  set  at  zero ;  but,  as 
the  vitality  of  the  drum  or  spring  is  per- 
manently lessened,  the  needle  does  not  give 
accurate  readings  at  other  points,  and  its 
condensed  scale  multiplies  the  natural  er- 
rors. 

The  auscultatory  method  of  obtaining 
the  diastolic  pressure  as  the  only  accurate 
and  simple  method  is  now  well  recognized. 
Here,  where  you  are  listening  over  the  ar- 
tery for  the  disappearance  of  sound,  if  you 
observe  the  dial  of  an  aneroid,  the  needle 
is  showing  wide  excursions,  making  it  im- 
possible to  determine  the  correct  reading, 
as  you  do  not  know  what  point  in  the  ex- 
cursion of  the  needle  to  note.  This  is  not 
the  case  in  a  good  mercurial  instrument 
where  the  fluctuation  of  the  mercury  is  but 
slight.    As  diastolic  readings  are  as  impor- 


26  BLOOD   PRESSURE 

tant  as,  if  not  more  so  than,  systolic,  the 
fact  that  the  correct  diastolic  reading  can- 
not be  obtained  is  a  serious  defect  in  this 
class  of  instruments. 

Of  these  instruments  Dr.  Richard  C. 
Cabot  makes  the  following  remarks  in  a 
paper  on  diagnosis:  **The  little  instru- 
ments which  are  widely  advertised  as  be- 
ing very  portable  are  splendid  for  the  first 
few  months,  but  if  you  do  many  high  pres- 
sures on  them,  like  any  other  aneroid  in- 
strument, they  give  out.  The  only  reliable 
machines  are  those  having  a  column  of 
mercury,  which  is  a  bother  to  carry 
around,  but  which  is  necessary.'' 

Finding  the  need  for  a  reliable,  accur- 
ate, durable,  simple,  portable,  and  inexpen- 
sive mercurial  apparatus,  the  author  has 
added  one  more  to  what  might  seem  an  al- 
ready well-filled  field.* 

The  instrument  shown  in  cut  No.  4  is 
simply  a  short  form  of  mercurial  instru- 
ment, utilizing  the  open-end  tube  with  a 
reservoir  and  so  arranged  that  the  mer- 

*  Instrument  described  in  Journal  American  Medical 
Association,  July,  1911. 


Fig.  6.— Nicholson  sphygmomanometer.  A,  steel  stopcock;  B,  needle-valve  air  releabe, 
C,  metal  connection  to  cuff  ;  D,  stopcock  for  tube  to  pump  ;  E,  rubber  connection  to  mercury 
reservoir;  F,  glass  reservoir  for  mercury:  G,  metal  air  pump;  H,  tube  to  pump;  i,  tuoe  to 
cuff;  J,  pneumatic  cuff  ;  K,  260  mm.  sliding  scale. 


IN   GENERAL   PRACTICE        27 

cury  needs  no  pouring,  and  cannot  be 
spilled.  By  the  use  of  a  steel  stopcock  and 
flint  glass  there  is  no  corrosion  of  the  mer- 
cury. The  instrument  is  only  13%  inches 
long,  and  when  closed  will  fit  in  the  ordi- 
nary doctor  ^s  bag. 

Accuracy  is  maintained  by  the  use  of  a 
full-length  mm.  scale  adjustable  to  the 
mercury  level,  allowing  for  changes  in  cli- 
mate and  temperature,  and  by  the  use  of 
a  wide,  easily  adjusted,  soft  cuff  (14  cm.). 

The  air  pressure  is  easily  and  steadily 
released  by  means  of  a  needle-valve,  and  a 
metal  pump,  or  single  rubber  bulb,  replaces 
the  unsatisfactory  double  rubber  bulb. 

The  manufacturers  have  made  the  price 
low  so  it  can  be  easily  obtained  by  the  gen- 
eral practitioner.* 

There  are  several  other  forms  of  accur- 
ate instruments,  but  owing  to  their  ex- 
pense and  size  they  are  not  available  in 
general  practice,  e.  g.,  the  Erlanger, 
Pachon,  Uskoff,  etc. 

*  Since  tlie  above  was  written  the  author  has  per- 
fected a  new  shorter  type  apparatus,  about  8  inches 
long,  making  it  much  more  portable,  but  retaining  all  the 
above-mentioned   features. 


28  BLOOD   PRESSUEE 


CHAPTER  III 

basic  factoes  on  which  blood  pressube 
depends;  diastolic  and  pulse  pres- 
sure ;   AND  NORMAL  READINGS 

IN  ORDER  to  utilize  blood-pressure  de- 
terminations, and  make  tliem  of  real 
value,  it  is  necessary  to  understand 
on  what  they  depend  as  well  as  what 
physiological  factors  are  involved,  and 
variations  possible  without  pathologic 
changes. 

While  from  a  theoretic  standpoint  there 
are  a  large  number  of  physiological  factors 
to  be  considered,  many  of  these  do  not, 
from  a  clinical  standpoint,  influence  blood- 
pressure  determinations  to  any  great  de- 
gree. 

Blood-pressure  Depends  on  Four  Main 
Factors— (1)  Cardiac  strength.  (2)  Per- 
ipheral   resistance    in    the    vessels.     (3) 


IN   GENERAL   PRACTICE        29 

The   elasticity  of  the  vessel  walls.     (4) 
The  volume  of  blood. 

Besides  these  there  are  several  other 
factors,  but  they  are  not  of  great  clinical 
importance,  e.  g.,  viscosity  of  the  blood, 

etc. 

The  heart  during  systole,  shortly  after 
the  beginning  of  its  contraction,  drives  the 
blood  out  into  the  aorta.  The  pressure  in 
the  aorta  then  reaches  the  maximum,  and 
shortly  after  the  aortic  valves  close.  The 
pressure  from  then  on  until  the  next  sys- 
tole is  maintained  by  the  elasticity  of  the 
vascular  walls,  and  as  the  blood  is  being 
forced  on  through  the  capillaries,  the  pres- 
sure gradually  falls,  and  reaches  its  mini- 
mum at  the  end  of  diastole. 

The  pressure  depends  mainly  on  the  con- 
tractile power  of  the  heart,  and  the  per- 
ipheral resistance  which  it  has  to  over- 
come, the  peripheral  resistance  depend- 
ing on  the  degree  of  contraction,  or  cali- 
ber of  the  vascular  walls,  and  also  on  their 
distensihility. 

The  caliber  of  the  vascular  walls  in  turn 


30  BLOOD   PRESSURE 

depends  on  tlie  vasomotor  center,  the  bal- 
ance between  vasoconstriction  and  vaso- 
dilatation, and  its  close  interaction  with 
the  heart  through  its  nerve  supply. 

As  can  he  easily  seen,  the  maximum  or 
systolic  pressure  approximates  the  intra- 
ventricular pressure,  while  the  minimal  or 
diastolic  pressure  represents  the  periph- 
eral resistance.  The  pulse  pressure,  or 
the  difference  between  the  two,  represents 
the  head  pressure  driving  the  blood  on  out 
through  the  arterioles  e,  g. 

Systolic    or    maximum. .  .150  mm.  Hg 
Diastolic    or   minimum. .  .120  mm.  Hg 


Pulse  pressure    30  mm.  Hg 

The  point  to  be  especially  emphasized 
is  that  the  maximum  or  systolic  pressure 
by  itself  indicates  mainly  heart  strength, 
but  equally,  if  not  more  important,  the  per- 
ipheral resistance  is  shown  by  the  mini- 
mum or  diastolic  pressure,  and  the  head  of 
flow  is  shown  by  the  pulse  pressure. 

In  the  past  very  little  work  has  been 
done  on  diastolic  and  pulse  pressure,  a  fact 


IN   GENEEAL   PEACTICE        31 

due  largely  to  the  difficulty  in  obtaining 
reliable  readings  with  the  instruments 
available  and  the  methods  used,  but  this  is 
no  longer  the  case  where  the  auscultatory 
method,  already  described,  is  utilized. 

Discussion  of  Pulse  Pressure  and  Dias- 
tolic Pressure.— Before  going  further  it 
might  be  well  to  consider  pulse  pressure 
(the  difference  between  systolic  and  dias- 
tolic readings)  and  diastolic  pressure  more 
in  detail. 

Various  figures  have  been  given  for  the 
normal  range  of  pulse  pressure : 

Erlanger     30  to  40  mm.  Hg 

Hirschf elder 30  to  45  mm.  Hg 

Young 25  to  30  mm.  Hg 

While  Lauder  Brunton  says :  *  *  Diastolic 
pressure  is  to  the  systolic  pressure,  under 
normal  conditions,  as  3  is  to  4.''  This 
gives  the  pulse  pressure  as  one-quarter  of 
the  systolic  reading. 

He  further  states:  '* Diastolic  pressure 
has  as  yet  received  comparatively  little  at- 
tention because  of  the  difficulty  of  ascer- 


32  BLOOD   PRESSUEE 

taining  it,  yet  it  is  a  factor  of  great  im- 
portance because  by  its  amount  and  by  the 
difference  between  it  and  the  systolic  pres- 
sure we  obtain  valuable  data  in  regard  to 
the  strength  of  the  heart  and  condition  of 
the  arterioles.'' 

In  substance  he  also  gives  the  follow- 
ing: 

Pulse  pressure  depends  on  the  pulse 
rate.  If  the  pulse  is  slowed  more  time  is 
allowed  for  the  blood  to  run  through  the 
arterial  system  during  diastole.  Diastolic 
pressure  will  be  lowered  and  pulse  pres- 
sure increased.    The  reverse  also  applies. 

A  weak  heart  will  not  raise  tension  as 
rapidly  as  a  strong  one,  and  the  time  be- 
tween the  end  of  each  systole  and  the  next 
will  be  shorter,  and  the  pulse  pressure 
lower.  In  a  stronger  heart  the  interval 
between  systoles  is  longer,  and  there  is  a 
larger  pulse  pressure. 

Now  turning  to  the  blood  vessels  we  find 
when  contracting  the  diastolic  pressure  re- 
mains high,  giving  a  small  pulse  pressure, 
and  vice  versa. 


IN    GENERAL   PRACTICE        33 

A  low  systolic  pressure  with  a  large 
pulse  pressure  shows  dilated  vessels  and 
a  probably  strong  heart. 

A  low  systolic  pressure  with  a  slight 
pulse  pressure  indicates  the  heart  itself  is 
weak;  in  addition,  there  is  probably  some 
dilatation  of  the  vessels,  though  a  feeble 
heart  with  normal  vessels  could  give  these 
signs. 

If  there  is  a  high  systolic  pressure,  and 
a  correspondingly  high  diastolic  pres- 
sure, giving  a  normal  pulse  pressure,  we 
may  assume  there  is  a  normal  balance  be- 
tween heart  and  vessels,  and  a  compensa- 
tory condition  is  present. 

Thus  pulse  pressure  is  of  the  greatest 
value  in  determining  the  condition  pres- 
ent, whether  mainly  due  to  heart  or  ar- 
teries, and  is  most  important  in  relation 
to  treatment.  By  observing  the  changes  in 
pulse  pressure  of  our  cases  under  treat- 
ment, we  obtain  the  most  accurate  idea 
possible  of  the  results  that  are  being  ob- 
tained; far  more  so  than  when  we  utilize 
the  systolic  pressure  alone. 


34  BLOOD   PEESSUEE 

If  the  systolic  pressure  approximates 
the  diastolic  pressure,  making  a  small 
pulse  pressure,  it  is  a  clear  indication  of  a 
failing  circulation.  This  condition,  if  con- 
tinued, would  cause  the  systolic  (maxi- 
mum) and  the  diastolic  (minimum)  pres- 
sures to  become  the  same,  at  which  point 
there  would  be  no  pulse  pressure  and 
death  would  have  taken  place,  as  the  car- 
diac strength,  shown  by  the  systolic  pres- 
sure, would  not  be  greater  than  the  per- 
ipheral resistance,  shown  by  the  diastolic 
pressure,  and  there  would  be  no  circula- 
tion of  the  blood. 

It  is  often  of  great  importance  to  know 
not  so  much  the  pressure  the  blood  is  un- 
der when  delivered  to  an  organ,  but  rather 
the  velocity  of  flow,  so  we  can  determine 
the  amount  of  blood  supplied.  Here  the 
pulse  pressure  determination  is  essential 
for  the  velocity  of  the  blood  stream  is 
roughly  equal  to  the  pulse  pressure  regis- 
tered in  mm.  Eg  multiplied  by  the  pulse 
rate  per  minute.  While  there  are  other 
factors  present,  and  this  is  not  absolutely 


IN   GENERAL   PRACTICE        35 

correct  in  every  case,  yet  in  general  this 
statement  is  correct,  and  gives  us  a  very 
good  idea  of  the  amount  of  blood  supplied 
to  an  organ.  In  general,  a  diminution  of 
pulse  pressure  means  a  lessened  velocity 
of  the  blood  flow,  pulse  pressure  being  in- 
dicative of  the  head  of  flow. 

Of  all  the  material  in  this  booklet  I  con- 
sider a  clear  conception  of  pulse  pressure, 
its  determination,  application,  and  mean- 
ing the  most  important. 

In  the  past  many  observers  have  been 
satisfied  with  the  determination  of  systolic 
pressure  alone,  and  wondered  why  their 
observations  were  useless  in  practical  di- 
agnosis and  treatment;  but  now  the  rea- 
son for  this  discrepancy  is  made  clear 
when  we  understand  the  obtaining  of 
accurate  pulse  pressure  and  its  interpre- 
tation. 

The  determination  and  application  of 
pulse  pressure  in  blood  pressure  work 
have  changed  the  entire  treatment  and  sig- 
nificance of  the  subject,  so  that  now  its  ap- 
plication to  general  medicine  is  wide  and 


36  BLOOD   PKESSURE 

of  a  practical  nature,  directing  us  to  a 
right  diagnosis,  giving  a  prognosis  and  a 
means  of  carrying  out  practical  and  scien- 
tific treatment. 

Blood-pressure  readings  without  the  de- 
termination of  the  diastolic  pressure  and 
the  estimation  of  the  pulse  pressure  are 
often  very  misleading,  since  they  furnish 
but  a  partial  estimation,  whereas  when  de- 
termined they  give  invaluable  information 
in  numerous  medical  and  surgical  condi- 
tions. 

Were  the  determination  of  the  diastolic 
pressure  any  longer  difficult  there  might  be 
some  excuse  for  not  obtaining  it  and  from 
it  finding  the  pulse  pressure,  but  by  the 
auscultatory  method  its  accurate  determi- 
nation has  been  made  so  simple,  being  as 
easily  and  quickly  determined  as  the  sys- 
tolic pressure,  that  there  is  no  longer  any 
reason  for  not  utilizing  it  and  obtaining 
the  pulse  pressure  in  every  case. 

The  taking  of  accurate  blood-pressure 
readings,  being  so  simple,  is  destined  in  a 
few  years  to  become  a  routine  procedure 


IN   GENEEAL   PRACTICE        37 

in  hospital  and  private  work,  taken  and 
charted  by  the  nurse  just  as  at  present  is 
done  in  the  case  of  pulse,  respiration  and 
temperature,  and  the  diastolic  and  pulse 
pressure  will  be  determined  in  every  case 
in  addition  to  the  systolic  pressure. 

Normal  Readings.— Before  turning  to 
the  consideration  of  blood-pressure  under 
abnormal  conditions,  let  us  consider  the 
normal  variations,  that  have  been  deter- 
mined by  numerous  observers. 

It  is  well  to  bear  in  mind  the  fact  that 
blood-pressure  standards  cannot  be  abso- 
lutely fixed,  there  being  considerable  vari- 
ation in  different  individuals. 


Age  Systolic    Diastolic 

Erlanger..l9  to  25  yrs 110  65    mm.  Hg 

Hirschf elder — All   ages    115-120         75-85 

Janeway — Before  mid.  life.  .100-130        25-40  mm.  lower 

than  systolic. 
After  mid.  life. .  .130-145        25-40 

Before   2d  yr 75-90 

After  2d  yr 90-110 

Normal — 

Cook— Before   30   years 120-130 

30  yrs.  on .125-140 


38  BLOOD   PEESSURE 

Abnormal — 

Before  mid.  life  pressure  above 145  mm.  Hg 

After  mid.  life  pressure  above 160  mm.  Hg 

Low  Limit — 

Janeway — Male    100  mm.  Hg 

Female    90  mm.  Hg 

Children—'  *  L.   Gordon '  '—Systolic 

MM. 

Under  one  year  71 

One  year    73 

Two  years   79.3 

Three  years  81 

Four   years    83 

Five  years   86.5 

Six  years   88.5 

Seven  years   85.0 

Eight  years  93 

Nine  years 100 

Ten   years 95 

Eleven  years  104 

Twelve   years    105 


In  general  it  may  be  stated  that  females 
are  about  10  mm.  lower  than  males. 

The  lowest  blood-pressnre  readings,  ac- 
cording to  Hensen,  were  40  mm.  systolic, 
and  lowest  possible  pressure  with  recov- 
ery was  approximately  55  mm. 

Cook  and  Briggs  consider  60  mm.  sys- 
tolic severe. 


IN   GENERAL   PRACTICE        39 

Janeway,  pressure  below  75  mni.  sys- 
tolic rare  except  during  operation,  when 
it  has  reached  40  mm. 

The  lower  limit  represents  the  resist- 
ance of  the  arterioles,  due  to  the  necessary 
vasomotor  tone,  and  is  probably  never  less 
than  50  mm.  mercury. 


40  BLOOD   PRESSUEE 


CHAPTER   IV 

PHYSIOLOGICAL    VARIATIONS    IN    BLOOD    PRES- 
SURE 

WHERE  there  are  no  pathological 
changes  present,  the  following 
factors  affecting  the  blood-pres- 
sure readings  are  found : 

Location  of  Cuff. — It  is  important  that 
the  constricting  cuff  shall  be  on  a  level 
with  the  heart ;  otherwise  the  correct  read- 
ing is  raised  or  lowered  by  the  effect  of 
gravity  on  the  column  of  blood,  according 
to  whether  the  constriction  is  below  or 
above  the  heart  level.  If  above,  the  read- 
ings will  be  too  low ;  if  below,  they  will  be 
too  high. 

Position  of  Patient. — The  position  of 
the  patient  in  relation  to  the  horizontal  is 
also  important,  systolic  pressure  being 
8-10  millimeters  higher  in  the  reclining 
than  in  the  sitting  posture. 


IN   GENERAL   PRACTICE        41 

There  is  about  the  same  difference  be- 
tween sitting  and  standing  posture.  The 
diastolic  pressure  also  rises  but  relatively 
higher  than  the  systolic,  and  as  a  result 
pulse  pressure  is  decreased.  The  pulse 
rate  is  also  increased.  The  main  point  is, 
therefore,  to  always  take  subsequent  read- 
ings on  the  same  patient,  in  the  same  pos- 
ture, when  possible. 

Meals. — There  is  a  moderate  rise  in  sys- 
tolic pressure  and  pulse  pressure  after 
meals,  and  the  pulse  rate  is  increased. 

Beeathii^g. — Deep  and  forced  breathing 
raises  blood-pressure  during  expiration, 
often  as  high  as  10  mm.,  and  lowers  it  dur- 
ing inspiration.  Quiet  breathing  has  no 
effect. 

Sleep. — During  sleep  the  maximum 
pressure  is  lowered  10  to  20  millimeters, 
due  to  relaxation  and  vasodilatation.  The 
fall  is  most  marked  in  minimal  pressure. 

Exeecise. — Exercise  causes  a  rise  in 
maximum  (systolic)  pressure,  and  an  in- 
crease in  pulse  pressure,  the  rate  being 
also  increased.    If  regular  exercise  is  se- 


42  BLOOD   PRESSURE 

vere,  there  may  be  a  rise  in  blood-pressure 
of  from  5  to  10  centimeters,  depending  on 
the  amount  of  force  exerted. 

If  exercise  is  carried  to  excess  and  fa- 
tigue ensues,  blood-pressure  falls,  and  the 
pulse  rate  is  slowed. 

Nervous  and  Mental  Stimuli. — Pain, 
anger,  emotion,  and  mental  effort  stimu- 
late vasoconstriction,  and  cause  a  rise  in 
blood-pressure,  especially  marked  in  mini- 
mal (diastolic)  readings.  The  pulse  is 
also  quickened. 

Mental  work  causes  a  marked  rise  in 
blood-pressure,  especially  when  combined 
with  worry  and  excitement,  mental  activ- 
ity being  roughly  proportionate  to  the 
height  of  the  blood-pressure. 

As  excitement  and  worry  cause  a  very 
marked  rise  in  blood-pressure  they  are 
often  dangerous  when  the  tension  is  al- 
ready high. 

Altitude. — Blood-pressure  rises  mark- 
edly with  an  increase  of  elevation.  An 
elevation  of  6,000  feet  will  give  an  average 
rise  of  10  mm.    On  returning  to  a  lower 


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IN   GENERAL   PRACTICE        43 

altitude  there  is  a  gradual  return  to  the 
former  level,  but  the  return  is  much  slower 
than  in  cases  of  high  tension  due  to  worry, 
excitement,  exercise,  or  mental  strain. 

Increased  blood-pressure  in  high  alti- 
tudes is  due  mainly  to  the  increased  heart 
action,  from  the  rapid  respiratory  move- 
ments in  rarefied  air,  but  also  to  a  minor 
degree  to  the  cooler  atmosphere  which 
causes  a  constriction  of  the  peripheral  ves- 
sels, increasing  the  peripheral  resistance, 
the  increased  amount  of  exercise  taken, 
and  the  greater  viscosity  of  the  blood. 

Cardiac  Cases. — In  cardiac  cases  cau- 
tion must  be  used  in  sending  patients  to 
high  altitudes. 

(a)  In  the  young,  free  from  organic 
heart  disease,  simply  worn  out  or  conva- 
lescent, high  altitudes  are  often  beneficial. 

(b)  In  middle  aged  and  elderly  patients 
use  care,  for  if  there  are  arteriosclerotic 
changes  or  the  heart  is  damaged,  high  alti- 
tudes are  dangerous.  Apoplexy  or  cardiac 
dilatation  may  ensue  as  the  reserve  force 
of  both  vessels  and  heart  is  lacking. 


44  BLOOD   PRESSURE 

In  Phthisis, — Here  high  altitude  is 
mainly  important  in  relation  to  hemor- 
rhage. In  the  young,  where  the  arteries 
are  resilient,  there  is  little  danger.  In 
middle-aged  there  is  a  real  risk,  and  if  the 
blood-pressure  is  elevated  do  not  send  to  a 
high  altitude. 

Time  Consumed  in  Taking  Readings. — 
If  constriction  is  continued  over  the  vessel 
for  one  minute  you  may  get  a  possible  rise 
of  5  mm.  Hg.  Continued  compression  may 
cause  a  rise  up  to  20  mm.  In  myocarditis 
a  lowered  pressure  results. 

Summary. — Take  all  readings  on  the 
same  patient  at  the  same  time  of  day,  pref- 
erably midway  between  meals.  Have  the 
patient  in  a  comfortable  position,  with 
muscles  relaxed,  best  reclining,  but  in  any 
case  make  all  subsequent  observations  in 
the  same  position.  Exclude  all  excitement, 
and  see  that  the  patient  is  mentally  com- 
posed, and  breathing  quietly.  Make  the 
determinations  as  rapidly  as  possible. 

If  the  above  precautions  are  observed, 
from  a  clinical  standpoint  there  will  be  no 


IN   GENERAL   PEACTICE         45 

important  error  in  tlie  pressure  values, 
providing  the  apparatus  is  accurate,  and 
the  auscultation  method  properly  em- 
ployed. 

Blood-pressure  is  also  affected  by  two 
pathological  conditions,  not  in  themselves 
diseases : 

(1)  Edema. — Here  the  reading  may  be 
too  high,  due  to  the  pressure  required  to 
squeeze  the  fluid  out  of  the  tissues.  Hen- 
sen  reports  in  one  case  an  error  of  20  mm. 
Hg. 

(2)  Asphyxia. — In  this  condition  we 
often  obtain  an  extreme  rise  of  pressure 
and,  in  slighter  grades  of  deficient  oxyge- 
nation of  the  blood,  a  rise  to  a  less  degree. 
This  condition  must  be  considered  in  dis- 
eases of  the  lung,  laryngeal  diphtheria, 
etc. 


46  BLOOD   PEESSUEE 


CHAPTEE  V 

HYPEETEKSIOIT 

CONSIDEEING  hypertension,  we  find 
that  where  it  is  not  due  to  the  fac- 
tors we  have  jnst  considered,  or  sec- 
ondary to  drugs,  as  digitalis,  adrenalin, 
strychnia,  ergot,  etc.,  there  is  an  increased 
peripheral  resistance  in  the  blood  vessels, 
which  has  been  found  to  depend  largely  on 
the  splanchnics. 

Another  important  point  is  the  fact  that 
continued  high  pressure  cannot  be  main- 
tained without  cardiac  hypertrophy,  and 
that  the  increased  tension  will  of  itself 
cause  changes  in  the  vessel  wall,  thicken- 
ing of  intima  and  media,  and  loss  of  elas- 
ticity, with  danger  of  rupture. 

Cases  of  hypertension  are  rapidly  be- 
coming more  frequent,  due,  in  large  ex- 
tent, to  the  increasing  stress  and  strain  of 


IN   GENERAL   PRACTICE        47 

business  life  and  the  associated  conditions 
of  overindulgence  in  food,  especially  pro- 
tein; too  rapid  eating;  the  drinking  of  too 
little  water;  too  little  healthful  exercise; 
the  keeping  of  late  hours,  with  lack  of  the 
proper  amount  of  sleep ;  the  use  of  undue 
mental  effort ;  and  the  excessive  use  of  al- 
cohol, tea,  coffee,  and  tobacco.  In  a  word, 
lack  of  good  hygiene. 

Hypertension  is  often  in  the  beginning 
primary  and  purely  a  spastic  condition 
prevailing  in  the  arterial  system  unaccom- 
panied by  organic  changes  in  the  vessel 
walls,  the  preliminary  stage  of  a  general- 
ized arteriosclerosis. 

It  is  important  to  discover  these  causes 
of  hypertension  early,  as  they  determine 
the  onset  of  a  condition  which,  if  con- 
tinued, will  cause  serious  and  permanent 
changes  in  the  vessel  walls,  which  in  turn 
produce  cardiac  hypertrophy,  with  its  sub- 
sequent weakening,  followed  by  failure  of 
compensation.  These  spastic  cases  are 
nearly  all  due  to  a  toxemia  and  can  be  re- 
lieved by  proper  regulation  of  the  bowels, 


48  BLOOD   PEESSUKE 

diet,  and  mental  and  physical  work.  In 
this  connection  the  importance  of  routine 
blood-pressure  determination  is  evident  in 
showing  a  condition  which  would  otherwise 
not  be  known  until  the  patient  were  forty 
or  past  and  permanent  damage  to  the  vas- 
cular walls  had  taken  place,  sufficient  for 
symptoms  to  develop  and  cause  the  patient 
to  consult  a  physician.  By  routine  exami- 
nations these  cases  would  be  detected  at 
their  onset  and  damage  prevented  by 
proper  prophylaxis. 

Even  after  organic  changes  in  the  ar- 
terial system  have  been  caused  there  is 
still  in  most  cases  some  spasm,  by  the  re- 
lief of  which  great  benefit  may  be  derived, 
and  the  development  of  more  vascular 
changes  prevented. 

The  treatment  of  hypertension  in  detail 
will  be  considered  more  fully  at  the  end  of 
this  section. 

It  might  be  well  now  to  turn  to  the  con- 
ditions in  which  hypertension  is  associated 
with  pathological  conditions  and  not  a  pri- 
mary condition  in  itself. 


IN   GENERAL   PRACTICE        49 

Angiosclerosis  (Dr.  T.  C.  Janeway).— 
**Aiigiosclerosis"  describes  a  rather  com- 
mon class  of  patients  who  have  a  perma- 
nent high  blood-pressnre  with  no  signs  of 
sclerosis  or  nephritis,  even  after  repeated 
examinations. 

These  cases  Janeway  considers  are  early 
chronic  interstitial  nephritis. 

Their  discovery  is  very  important  in  or- 
der to  prevent  cardiac  hypertrophy  and 
vascular  changes,  which  are  inevitable  if 
the  condition  of  high  tension  is  not  re- 
lieved. 

Treatment. — Here  it  is  important  to 
regnlate  the  diet,  eliminate  as  far  as 
possible  overwork  and  worry,  keep  the 
intestinal  tract  open,  and  the  bowel 
function  active,  as  many  of  these  cases 
are  due  to  a  certain  amount  of  auto- 
intoxication. Sweating  is  also  of 
value. 

Caution, — Do  not  use  vasodilators  until 
all  other  methods  fail,  or  the  pressure  is 
such  that  it  demands  immediate  relief, 
there  being  danger  of  rupture  of  the  ves- 


50  BLOOD   PRESSURE 

sels;  then  use  nitrates,  and  if  necessary 
bleed. 

High  blood-pressnre  is  often  compensa- 
tory and  by  lowering  it  harm  is  done. 

Angina  Pectoris.— There  are  a  large 
number  of  patients  complaining  of  mild 
angenoid  symptoms,  tightness  under  the 
sternum,  dyspnea  on  exertion,  and  belch- 
ing after  meals,  which  are  accompanied  by 
high  blood-pressure. 

These  are  cases  of  mild  angina  pectoris. 

*  *  Given  angenoid  symptoms  with  marked 
hypertension  (systolic  180  mm.  or  over), 
you  are  probably  dealing  with  angina  pec- 
toris.'*    (Janeway.) 

The  reverse  of  Dr.  Janeway 's  statement, 
however,  does  not  follow,  for  while  in  a 
number  of  cases  there  is  an  associated  ar- 
teriosclerosis of  the  aorta  and  coronary 
arteries,  with  a  high  arterial  tension,  in 
many  cases  there  are  marked  attacks  of 
angina  pectoris  without  increased  blood- 
pressure.  No  less  an  authority  than  Dr. 
James  Mackenzie  considers  that  blood- 
pressure  is  normal  or  lowered  during  the 


IN   GENERAL   PRACTICE        51 

attack,  for  he  says :  ^  ^  I  can  only  infer  that 
cases  of  arterial  spasm  are  very  excep- 
tional and  their  description  fostered  by 
the  relief  obtained  by  the  administration 
of  amyl  nitrite  has  given  a  wrong  concep- 
tion in  regard  to  the  condition  inducing  an 
attack  of  angina  pectoris.  I  have  found 
during  the  attack  the  pulse  becomes  small, 
soft,  and  scarcely  perceptible,  from  weak- 
ness of  the  heart,  the  heart  sounds  becom- 
ing very  faint.  I  have  also  found  an  ac- 
celeration of  the  heart  rate.  I  could  de- 
tect no  change  in  the  heart  or  arteries,  and 
there  never  was  the  slightest  enlargement 
of  the  heart  coming  on  during  the 
attack. ' ' 

Dr.  William  Osier  gives  a  good  sum- 
mary of  this  subject  when  he  says : 

**The  pulse  tension,  however,  is  usually 
increased,  but  it  is  surprising,  even  in  the 
cases  of  extreme  severity,  how  slightly  the 
character  of  the  pulse  may  be  altered.'' 

Arteriosclerosis.— Here  our  diagnosis  of 
the  existence  of  sclerosis  rests  on  the 
palpation  of  the  hardened  vessel  walls, 


52  BLOOD   PEESSUEE 

visible  tortuosity,  or  we  may  reason  it  is 
present  from  the  sclerosed  vessels  in  the 
eye-ground,  the  enlarged  left  ventricle,  the 
ringing  aortic  second  sound,  with  high 
blood-pressure. 

Numerous  observations  have  shown  that 
unless  the  splanchnic  vessels  or  the  aortic 
artery  above  the  diaphragm  are  affected 
there  are  not  likely  to  be  an  increased 
blood-pressure  and  hypertrophy  of  the 
heart,  but  whenever  the  splanchnics  are 
sclerosed  the  blood-pressure  is  elevated. 

In  this  condition  the  systolic  pressure  is 
greatly  increased  (159-170  mm.  to  250 
mm.).  The  diastolic  pressure  increases 
(110-130  mm.),  but  not  proportionately, 
thus  increasing  the  pulse  pressure  greatly 
(60  mm.  or  over). 

We  cannot  assume  that  where  there  is 
a  high  blood-pressure  without  tangible  or- 
ganic lesions  we  are  dealing  with  arterio- 
sclerosis, as  not  all  cases  of  arterio- 
sclerosis raise  tension,  and  certain  other 
factors  have  also  to  be  considered  as : 

(1)  Pain,   mental   and  nervous   excite- 


IN   GENERAL  PRACTICE        53 

ment,  etc.,  mentioned  under  physiological 
factors  (page  40). 

(2)  Drugs,  e.  g.,  nicotine,  which  by  its 
direct  effect  on  the  arterial  wall  raises  ten- 
sion, though  where  long  continued  it  low- 
ers tension,  owing  to  its  toxic  action  on 
cardiac  muscle. 

(3)  Such   conditions   as   asphyxia   and 

edema. 

(4)  In  addition  there  are  certain  toxic 
conditions  of  increased  internal  secretion 
as  where  the  adrenals  or  pituitary  bodies 
are  overactive,  in  which  case  the  tension 
might  be  high  without  any  sclerotic 
changes  being  present. 

While  the  role  of  primary  arterio- 
sclerosis in  causing  high  blood-pressure  is 
limited,  being  associated  with  hypertension 
in  only  fifty  per  cent,  of  the  cases  (where 
the  generalized  sclerosis  affects  the 
splanchnics  or  the  aorta  above  the  dia- 
phragm), hypertension,  no  matter  what  its 
source  may  be,  if  continued,  causes  changes 
in  the  vessel  walls  producing  marked 
sclerosis  and  cardiac  hypertrophy. 


54  BLOOD   PRESSUEE 

Arteriosclerosis  as  a  result  of  continued 
high  tension  of  course  is  accompanied  by  a 
high  blood-pressnre,  but  in  arteriosclerosis 
due  to  the  toxine  of  infection  often  the 
blood-pressure  is  normal  or  if  raised  it  is 
later  in  the  process.  Pure  senile  arterio- 
sclerosis has  no  associated  hypertension. 

Dr.  R.  D.  Rudolph  says:  ^^It  is  safe  to 
argue  in  cases  of  arteriosclerosis  with  in- 
creased pressure  that  the  relative  differ- 
ence between  the  systolic  and  diastolic 
pressures  {pulse  pressure,  auth.)  would  he 
a  measure  of  the  degree  to  which  the  in- 
creased pressure  was  due  to  the  sclerosis 
of  the  arterial  tract  between  the  heart  and 
the  point  at  which  the  pulse  is  being  felt/' 

There  is  no  way  of  diagnosing  cerebral 
arterial  degeneration  absolutely  from  the 
general  blood-pressure,  but  the  probability 
of  its  presence  should  be  borne  in  mind 
where  there  is  superficial  sclerosis  asso- 
ciated with  a  moderate  elevation  of  blood- 
pressure. 

Sir  T.  Clifford  Albutt,  in  speaking  of 
this  subject,  lays  down  the  rule  that  every 


IN   GENERAL   PEACTICE        55 

individual  over  forty  should  liave  blood- 
pressure  taken  every  four  or  five  years, 
that  he  may  know  if  there  is  a  tendency 
to  arteriosclerosis,  the  presclerotic  stage 
being  noted  long  before  the  heart  is  af- 
fected. 

In  conclusion,  I  wish  to  call  attention  to 
two  important  points:  (1)  That  arterio- 
sclerosis is  often  so  closely  associated  with 
diseases  producing  high  tension,  as  ne- 
phritis and  cardiac  conditions,  that  the 
hypertension  present  in  such  cases  is  due 
to  the  associated  disease  and  not  to  the 
arteriosclerosis.  These  diseases  will  be 
considered  under  their  separate  heads. 

(2)  There  is  a  class  of  patients  who 
have  had  a  high  arterial  tension,  but  owing 
to  a  marked  myocarditis  and,  in  some 
cases,  cardiac  dilatation,  resulting  from 
the  continued  high  tension,  the  high  sys- 
tolic pressure  in  the  early  stages  becomes 
about  normal  in  height,  or  even  a  little 
lower  than  normal.  These  cases  are  more 
serious  than  those  in  which  the  tension  re- 
mains high,  as  they  show  that  the  com- 


66  BLOOD  PEESSUEE 

paratively  higli  tension  can  no  longer  be 
maintained  by  the  heart.  Many  serious 
mistakes  have  been  made  by  considering 
such  cases  as  in  good  health  because  the 
systolic  pressure  is  about  the  normal  level 
or  lower.  These  cases  can  easily  be  diag- 
nosed if  the  diastolic  pressure  be  taken  as 
well  as  the  systolic,  for,  while  the  heart 
muscle  cannot  maintain  the  systolic  pres- 
sure, the  peripheral  resistance  in  the  ves- 
sels, due  to  the  sclerosed  condition  of  their 
walls,  remains  and  maintains  a  relatively 
high  diastolic  pressure,  giving  a  small 
pulse  pressure. 

The  treatment  of  this  condition  will  be 
considered  under  hypertension. 

Autointoxication.— Here  is  often  found 
a  markedly  elevated  blood-pressure,  but  in 
some  cases  where  there  is  marked  consti- 
pation the  pressure  may  be  low. 

As  Dr.  W.  H.  Sheldon  aptly  puts  it: 
**  Headaches  and  dizziness  supposed  to  be 
due  to  high  pressure  I  have  again  and 
again  seen  disappear  with  laxatives  and 
diet  and  no  change  in  the  blood-pressure. 


IN   GENERAL   PRACTICE        57 

Most  of  the  cases  given  above  had  in- 
creased indican  in  the  urine,  and  I  am  in- 
clined to  believe  that  the  headaches  and 
dizziness  are  due  more  to  intestinal  putre- 
faction than  high  pressure." 

Diabetes.— In  this  disease  blood-pres- 
sure determinations  are  of  no  value  from 
either  a  diagnostic  or  prognostic  stand- 
point, as  the  disease  only  affects  the  height 
of  blood-pressure  when  complicated  by 
other  conditions,  e.  g.,  arteriosclerosis. 
When  there  is  a  marked  acidosis  there  is 
a  rather  marked  rise  in  blood-pressure 
proportionate  to  the  degree  of  acid  intoxi- 
cation. 

Drugs.— Here  will  be  mentioned  briefly 
only  those  drugs  which  produce  hyperten- 
sion, those  reducing  arterial  tension  being 
mentioned  under  the  treatment  of  hyper- 
tension. 

Briggs  and  Cook,  in  an  extensive  series 
of  experiments  at  the  Johns  Hopkins  Hos- 
pital, obtained  some  very  valuable  infor- 
mation as  to  the  blood-pressure-raising 
value  of  drugs,  finding: 


68  BLOOD   PRESSUEE 

Adrenalin,  when  administered  intrave- 
nously, raised  tlie  blood-pressure  to  any 
desired  height,  but  was  transitory. 

Cocaine  in  post-operative  low  tension 
and  in  hemorrhage  given  in  doses  of  %-% 
a  grain,  hypodermically,  produced  an  al- 
most immediate  rise  in  blood-pressure  of 
10  to  20  mm.,  which  was  maintained  1  to  3 
hours. 

Camphor  proved  generally  inert.  In 
weakened  cardiac  systole  and  in  acute  toxic 
cardiac  dilatation,  it  produced  good  results, 
but  the  same  conditions  were  amply  cov- 
ered by  strychnia  and  digit alin. 

Digitalis,  when  given  as  digitalin  hypo- 
dermatically,  was  more  certain  to  raise  the 
blood-pressure  than  strychnia,  its  action 
was  manifest  earlier,  reached  a  maximum 
sooner,  but  the  action  was  not  so  long 
maintained.  Given  in  doses  of  1-20  to  1-10 
of  a  grain  hypodermatically,  digitalin 
often  caused  a  rise  when  strychnia  failed, 
blood-pressure  being  maintained  by  a  com- 
bination of  the  two. 


IN   GENERAL   PRACTICE        59 

Normal  saline  solution  was  found  of  lit- 
tle value  in  cases  of  shock,  unless  there 
was  added  14  to  1/2  a  grain  of  cocaine,  or 
10  minims  of  adrenalin  to  the  intravenous 
injection. 

In  hemorrhage,  when  the  bleeding  point 
had  been  secured,  the  saline  solution  raised 
the  blood-pressure,  by  increasing  the  vol- 
ume of  the  blood,  and  was  found  very  val- 
uable. 

Strychnia  in  doses  of  1-60  to  1-10  of  a 
grain  raised  blood-pressure,  and  its  effect 
was  maintained  from  one  to  four  hours. 
After  eight  to  twelve  doses  there  was  no 
further  rise,  but  if  one  or  two  doses  were 
omitted  the  pressure  fell,  but  could  be 
raised  again  by  renewed  administration  of 
the  drug.  ^^On  the  whole,  strychnia  is  by 
far  the  most  satisfactory  cardiovascular 
stimulant  for  long  continued  routine  ad- 
ministration.'' Doses  of  1-20  to  1-10  of  a 
grain  hypodermatically  produced  a  quick 
response,  raising  the  blood-pressure  80-100 
mm.    A  dose  of  1-20  of  a  grain  often  gives 


60  BLOOD  PRESSUEE 

a  40-mm.  rise,  lasting  one  hour.  When  the 
pressure  begins  to  fall  it  may  be  main- 
tained by  a  smaller  dose. 

Among  other  drugs  which  elevate  blood- 
pressure  are: 

Atropine,  increasing  both  cardiac  energy 
and  peripheral  resistance. 

Pituitary  extract  (^^Vaparole'')  1  c.  c. 
twice  daily  gives  a  marked  and  sustained 
rise,  but  causes  severe  symptoms,  and  at 
the  present  writing  is  not  a  safe  drug  to 
use  in  reduced  blood-pressure. 

Caffein,  in  the  form  of  the  citrate,  10 
grains  three  times  a  day,  is  very  efficient, 
and  is  next  to  pituitary  extract  in  the 
strength  of  its  reaction.  Caffein  must  not 
be  used  in  tea  drinkers. 

Tea  and  coffee  both  produce  a  transi- 
tory rise.  Subjects  who  indulge  freely 
often  have  a  high  tension,  which  leads  to 
arteriosclerosis. 

Ergot  produces  a  slight  elevation  of 
blood-pressure  due  to  its  vasoconstricting 
effect. 

Epilepsy,   Idiopathic— It  is  associated 


IN   GENERAL   PRACTICE        61 

with  a  slow  pulse  and  a  high  blood-pres- 
sure, which  falls  with  the  termination  of 
the  attack,  the  fall  of  the  high  blood-pres- 
sure being  an  aid  in  the  differential  diag- 
nosis of  the  post-epileptic  state  and 
uremia,  as  in  the  latter  there  would  be  a 
maintained  pressure  during  coma. 

Exophthalmic  Goiter.— Blood-pressure 
is  variable,  but  as  the  disease  is  often  ac- 
companied by  a  hypertrophied  heart,  the 
systolic  pressure  is  often  raised,  e.  g., 

Systolic 140-160  mm.  Hg 

Diastolic  90-110  mm.  Hg 

Pulse   pressure    30-50  mm.  Hg 

Pulse   rate    120  or  more 

Eye  Diseases.— In  diseases  of  the  eye 
high  arterial  tension  plays  a  very  impor- 
tant role,  and  the  determination  of  blood- 
pressure  is  very  valuable  in  the  diagnosis, 
prognosis,  and  treatment  of  many  ocular 
conditions. 

The  routine  determination  of  blood-pres- 
sure in  such  cases  is  imperative,  for  by 
means  of  it  many  cases  of  high  blood-pres- 
sure are  discovered  and  corrective  treat- 


62  BLOOD   PRESSUEE 

ment    instituted    before    any    extensive 
ocular  changes  have  taken  place. 

It  is  now  well  recognized  that  a  high 
arterial  tension,  if  maintained,  no  matter 
from  what  exciting  cause,  will  produce 
sclerotic  changes  in  the  walls  of  the  ar- 
teries, affecting  the  general  vascular  sys- 
tem (see  hypertension),  and  the  vascular 
system  of  the  eye  being  part  of  the  per- 
ipheral circulation  is  also  affected. 

Not  only  is  the  determination  of  high 
blood-pressure  in  relation  to  eye  diseases 
of  importance  to  the  oculist  but  also  to 
the  internist  and  general  practitioner,  for 
when  the  general  practitioner  discovers  he 
has  a  case  of  high  arterial  tension  he 
should  think  of  the  possible  conditions 
which  might  result  from  such  hyperten- 
sion, not  only  to  the  general  circulation, 
but  also  to  the  special  organs  of  the  body. 

In  many  cases  by  consulting  with  a  com- 
petent oculist  at  once  the  patient  may  be 
saved  much  damage  to  the  eye  by  the  im- 
mediate adoption  of  corrective  measures. 

The  following  are  the  most  important 


IN   GENERAL   PRACTICE        63 

ocular  conditions  in  whicli  increased  blood- 
pressure  is  significant: 

Spasm  of  the  Retinal  Vessels. — There 
are  a  number  of  patients  with  temporary 
unilateral  blindness,  sudden  in  onset,  and 
lasting  from  ten  minutes  to  half  an  hour. 
Both  eyes  may  be  affected,  but  not  at  the 
same  time. 

In  a  few  of  these  cases,  where  the  pa- 
tients could  be  examined  during  an  attack, 
the  ophthalmoscope  showed  a  blanching  of 
the  retinal  vessels,  due  to  the  arterial 
spasm,  disappearing  when  the  attack  ter- 
minated. These  attacks  were  invariably 
associated  with  high  arterial  tension,  and 
under  proper  treatment  directed  to  the 
lowering  and  maintenance  of  a  normal 
blood-pressure  such  cases  do  well  and 
often  are  prevented  from  developing  ac- 
tual sclerotic  changes  in  the  vessel  walls. 
Even  if  treatment  is  not  instituted  until 
late  in  the  course  of  the  disease,  further 
damage  can  often  be  prevented,  but  the 
important  point  is  to  discover  the  condi- 
tion early,  while  it  is  purely  an  arterial 


64  BLOOD   PEESSUEE 

spasm  without  any  actual  arterial  change. 

Untreated,  these  cases  are  followed  by 
marked  sclerotic  vascular  changes,  and  in 
many  thrombi  and  emboli  are  formed,  with 
all  their  serious  and  lasting  effects. 

Cataract. — In  this  class  of  cases  there 
are  so  many  sclerotic  changes  (the  catar- 
act being  part  of  a  general  sclerotic  proc- 
ess), high  tension  is  almost  universal. 
Most  ophthalmologists  do  not  consider  that 
the  sclerosis  present  contraindicates  cat- 
aract extraction,  but  these  cases  often  de- 
velop a  post-operative  intraocular  hemor- 
rhage due  to  the  arterial  hypertension, 
with  resulting  blindness. 

By  a  determination  of  the  blood-pres- 
sure before  operation  and  the  institution 
of  preparative  treatment,  i.  e.,  such  as 
bleeding,  etc.,  the  arterial  tension  may  be 
lowered  and  subsequent  intraocular  hem- 
orrhage prevented.  A  bleeding  of  from 
eight  to  sixteen  ounces  lowers  the  blood- 
pressure  markedly,  the  amount  required 
being  determined  by  the  sphygmoma- 
nometer readings,  and  as  the  tension  re- 


IN   GENERAL   PRACTICE        65 

mains  low  for  several  days,  it  gives  the 
eye  time  to  become  accustomed  to  its  new 
condition  and  intraocular  hemorrhage  is 
thus  prevented. 

Chronic  Interstitial  Nephritis  in  Rela- 
tion to  the  Eye. — This  subject  is  very 
clearly  treated  by  Dr.  Luther  C.  Peter 
when  he  says:  ^^In  chronic  interstitial  ne- 
phritis more  or  less  direct  relation  between 
the  height  of  the  tension  and  the  severity 
of  the  symptoms  is  observed,  modifying 
influences  being  age,  degree  of  arterio- 
sclerosis, the  duration  of  the  high  tension 
and  the  individual  resisting  power. 

*^  Other  things  being  equal,  the  amount 
of  retinal  disease  will  be  in  proportion  to 
the  height  and  duration  of  the  increased 
tension. 

**  Increased  blood-pressure  is  one  of  the 
earliest  premonitory  signs  of  arterio- 
sclerosis and  chronic  interstitial  nephritis, 
and  possibly  acts  as  a  causative  factor, 
and  second  that  arterial  hypertension  is 
the  cause  of  early  retinal  and  arterial 
changes  as  well  as  later  phenomena." 


66  BLOOD   PEESSUEE 

Glaucoma. — Hypertension  is  now  con- 
sidered by  the  majority  of  ophthalmologists 
to  be  the  probable  causative  factor  in  cases 
of  glaucoma. 

Hypertension  is  invariably  present  and 
affords  a  very  valuable  means  of  diagnosis 
as  also  indications  as  to  treatment. 

Retinal  Hemorrhage. — Eetinal  hemor- 
rhage of  non-traumatic  origin  is  due  to  in- 
creased blood-pressure. 

Dr.  Peter,  in  a  review  of  this  subject, 
gives  the  following  summary: 

'*  Arterial  hypertension  is  the  chief 
cause  of  eye  ground  phenomena  observed 
in  chronic  interstitial  nephritis  and  ar- 
teriosclerosis. 

'*  Senile  vascular  changes,  associated 
with  high  blood-pressure,  may  be  observed 
at  times,  before  these  diseases  are  diag- 
nosed by  other  clinical  symptoms. 

*'It  frequently  acts  as  a  cause  for  sub- 
conjunctival hemorrhage  and  is  so  closely 
associated  with  glaucoma  that  it  should  be 
regarded  as  an  active  factor  in  the  devel- 
opment of  the  disease. 


IN   GENERAL   PEACTICE        67 

^'It  probably  will  help  to  explain  the 
phenomena  of  intraocular  hemorrhage 
after  cataract  extraction. 

^^In  order  to  prevent  and  to  treat  ration- 
ally the  more  serious  eye  conditions  rou- 
tine blood-pressure  studies  should  be  made 
in  all  cases  of  intraocular  disease  not 
traumatic. '  ^ 

Gout.— Gives  increased  tension  both 
during  the  attack  and  between  attacks, 
when  arterial  changes  are  marked. 

Heart  Disease.— This  subject  will  be 
treated  under  its  several  divisions  as  the 
different  forms  of  cardiac  disease  are 
fairly  well  defined.  Angina  pectoris  has 
already  been  treated  under  a  separate 
head  so  will  not  be  mentioned  here. 

Aortic  Regurgitation, — Here  is  found  a 
systolic  pressure  75  to  100  per  cent,  higher 
than  the  diastolic,  the  pulse  pressure  be- 
ing very  high.  In  some  cases  120  to  130 
mm.  systolic,  diastolic,  50  to  60  mm.,  in 
other  cases  often  170  to  220  mm.  systolic, 
diastolic  60  to  140  mm.;  but  in  all  cases 
the  pulse  pressure  is  great. 


68  BLOOD   PEESSUEE 

When  you  auscult  over  the  artery  in 
taking  the  blood-pressure  reading  you 
often  note  a  continuance  of  sound  (an  aid 
in  diagnosing  this  condition),  so  that  the 
diastolic  pressure  in  these  cases  has  to  be 
determined  by  palpation  in  almost  all  se- 
vere cases. 

In  well  compensated  cases  sound  does 
disappear. 

Dr.  Leonard  Hill  showed  that  in  health 
blood-pressure  is  about  the  same  in  both 
the  brachial  and  femoral  arteries,  but  in 
aortic  regurgitation  the  readings  from  the 
femoral  are  much  higher. 

When  the  relation  of  pulse  pressure  to 
the  diastolic  reading  is  low,  in  a  doubtful 
case,  it  is  not  likely  that  there  is  aortic  in- 
sufficiency. 

Chronic  Cardiac  Hypertrophy. — Here 
we  have  an  increase  in  both  systolic  and 
diastolic  pressure  (systolic  140  to  160  mm., 
diastolic  90  to  110  mm.  Hg). 

Cardiac  Valve  Lesions  Other  Than 
Aortic. — Blood-pressure  in  these  cases  is 
about  normal  when  compensation  is  good. 

Heart  with  Loss  of  Compensation  and 


IN   GENERAL   PRACTICE        69 

Asthma. — Here  is  found  high  tension  from 
associated  asphyxia:  when  severe  actual 
edema  of  lungs  takes  place  and  life  is  in 
danger,  the  blood  being  loaded  with  car- 
bon dioxide,  immediate  relief  must  be 
given;  e.  g.,  bleeding,  amyl  nitrite,  nitro- 
glycerine, and  later,  after  acute  condition 
is  relieved,  give  cardiac  stimulants. 

Myocarditis. — There  are  many  cases  of 
myocarditis  not  discoverable  by  physical 
examination  either  because  of  their  slight 
degree  or  because  in  fat  subjects  with 
large  chest  walls  clear  physical  signs  are 
impossible  to  obtain.  It  is  in  these  cases 
that  blood-pressure  helps  not  only  to  make 
the  diagnosis  but  also  to  determine  the  ex- 
tent of  the  disease. 

A  condition  of  myocarditis  and  a  good 
general  idea  of  its  extent  can  be  deter- 
mined by  means  of  a  functional  test  de- 
vised by  Graupner. 

Take  the  pulse  rate  and  the  blood-pres- 
sure of  the  patient  to  be  tested  and  then 
give  a  prescribed  amount  of  exercise,  as 
walking  up  a  certain  number  of  steps,  etc., 
then  take  the  pulse  rate  and  the  blood-pres- 


70  BLOOD   PRESSURE 

sure  every  five  minutes.  A  normal  heart 
will,  during  exercise,  cause  a  rise  of  blood- 
pressure  associated  with  an  accelerated 
pulse  rate. 

The  blood-pressure  and  the  pulse  rate 
will  remain  elevated  during  the  exercise 
unless  it  is  excessive  or  unduly  prolonged. 
With  a  cessation  of  the  exercise  both 
blood-pressure  and  pulse  will,  in  a  short 
time,  return  to  their  previous  level,  the 
pulse  rate  a  little  before  the  blood-pres- 
sure. 

In  myocarditis  cases,  if  mild,  there  will 
be  an  elevation  of  blood-pressure  and  an 
acceleration  of  the  pulse  rate,  but  the 
blood-pressure  in  a  short  time  will  fall 
below  or  to  its  previous  level,  while  the 
pulse  rate  remains  high  longer.  In  some 
severe  cases  the  blood-pressure  will  fall 
from  the  start,  the  pulse  rate  increasing, 
the  blood-pressure  rising  to  its  previous 
level  only  after  a  long  time. 

In  addition  there  are  myocarditis  cases 
of  large,  weak  hearts  with  dyspnea,  edema, 
and  subjective  symptoms: 


IN   GENERAL   PKACTICE        71 

(1)  AVith  hypertension. 

(2)  Without  hypertension. 

(1)  These  are  cases  secondary  to 
Bright 's  disease  or  arteriosclerosis,  or  are 
primary  myocarditis  cases  which  have  de- 
veloped Bright 's. 

(2)  These  are  primary  uncomplicated 
cases  of  myocarditis  or  in  the  terminal 
stage  of  the  secondary  type. 

The  primary  cases  usually  show  a  high 
normal  blood-pressure,  and  are  more  lia- 
ble to  have  edema  (systolic  135  to  145  mm. 
Hg). 

Acute  Endocarditis. — It  is  associated 
with  a  low  systolic  pressure. 

Bradycardia. — Here  the  pulse  pressure 
is  increased. 

Cardiac  Arrhythmia. — There  are  many 
cases  of  arrhythmia  purely  functional  in 
character,  but  there  are  also  a  number 
with  true  organic  disease.  It  is  in  these 
doubtful  cases  that  blood-pressure  deter- 
minations are  of  great  value. 

In  discussing  physical  diagnosis  Dr. 
Eichard  C.  Cabot  says: 


72  BLOOD   PEESSUEE 


(  c 


On  the  other  side  are  irregular  hearts 
which  you  finally  believed  to  be  merely 
functional  in  origin  and  to  have  no  imme- 
diate significance,  because  the  blood-pres- 
sure is  normal.  An  irregular  heart  plus  a 
high  blood-pressure  is  serious.  The  very 
same  heart  with  low  blood-pressure  may 
be  of  no  significance.'' 

Dr.  Cabot  further  makes  this  statement 
about  cardiac  cases  in  general:  ^^ Patients, 
the  examination  of  whose  hearts  does  not 
show  anything  certainly  characteristic  of 
disease,  have  often  been  shown  to  be  dis- 
eased, or  proven  later  to  be  diseased,  by 
the  high  blood-pressure  registered  by  the 
machine,  pressure  which  my  fingers  are 
not  able  to  detect  in  feeling  the  pulse  at 
the  periphery/^ 

Increased  Intracranial  Tension.— ^po- 
plexy,  Cerebral  Thrombrosis,  Depressed 
Fracture  of  the  Skull,  Fracture  of  the 
Base,  Jacksonian  Epilepsy,  Intracranial 
Hemorrhage,  Tumors  (rapid  growing 
cerebral). 

In  these  conditions  of  increased  intra- 


IN   GENEEAL   PRACTICE        73 

cerebral  pressure  tlie  highest  blood-pres- 
sure readings  occur.    Hirschfelder  gives 

Systolic    300-400  mm. 

Diastolic    160  mm.  or  over 

Pulse  slowed. 

The  high  pressure  is  compensatory  and 
is  the  effort  to  supply  more  blood  against 
the  increased  intracerebral  tension  and 
thus  prevent  anemia  of  the  brain. 

The  important  point  is  not  to  bleed,  and 
try  to  lower  the  pressure,  but  to  operate 
where  possible,  and  where  not,  to  give 
atropine  to  paralyze  the  vagus,  and  to  al- 
low the  pressure  to  rise  more  rapidly. 

In  a  case  of  head  injury  the  blood-pres- 
sure reading  is  of  great  value ;  for  in  con- 
cussion the  pressure  is  low,  whereas  in  the 
above-named  conditions  it  is  invariably 
high,  unless  very  late  when  cerebral 
paralysis  has  developed. 

Nephritis.— In  nephritis,  especially  in 
the  chronic  forms,  blood-pressure  deter- 
minations are  one  of  the  most  valuable 
means  of  diagnosis.    Dr.  Richard  C.  Cabot 


74  BLOOD   PEESSURE 

says:  '^Then  calling  your  attention  to  the 
early  diagnosis  of  kidney  lesions,  I  see  a 
good  many  cases  of  renal  disease  entirely 
free  from  albuminuria  or  from  casts,  but 
with  high  blood-pressure,  which  are  shown 
later,  post  mortem,  to  be  renal  disease. 
These  cases  could  not  have  been  suspected 
to  be  renal  disease  except  by  blood-pres- 
sure. In  other  words,  I  regard  the  blood- 
pressure  measurements  as  of  more  impor- 
tance than  the  examination  of  the  urine  in 
chronic  kidney  trouble.  Examination  of 
the  urine  has  again  and  again  led  me 
astray,  the  measurement  of  the  blood-pres- 
sure almost  never. ' ' 

(A)  Chronic  interstitial  nephritis  gives 
a  high  systolic  pressure  (200  mm.  or 
higher),  and  a  relatively  low  diastolic  pres- 
sure; giving  a  large  pulse  pressure  (60  to 
80  mm.  Hg). 

Here  hypertension  is  one  of  the  most 
important  signs,  often  making  the  diag- 
nosis in  obese  individuals,  where  the  en- 
largement of  the  heart  is  hard  to  define 
and  the  urine  negative  for  a  long  time. 


IN   GENERAL   PRACTICE        75 

Dr.  T.  C.  Janeway  says:  ''Given  a  sys- 
tolic pressure  of  over  200  mm.,  the  diag- 
nosis of  contracted  kidney  must  be  dis- 
proved by  repeated  examinations  before  it 
is  abandoned." 

Caution,— If  the  heart  has  failed  to 
compensate,  the  pressure  may  be  low,  and 
it  is  here  that  the  pulse  pressure  will  aid 
materially. 

In  this  condition  the  pulse  pressure  is 
lessened. 

The  prognosis  depends  not  so  much  on 
the  actual  height  of  the  mercurial  column 
as  on  a  pressure  which  is  rising  or  resist- 
ant to  treatment.  The  ultimate  danger  is 
rupture  and  apoplexy. 

(B)  Chronic  Parenchymatous  Nephritis, 
— In  it  the  blood-pressure  is  uncertain, 
often  being  normal.  "When  there  is  hyper- 
tension it  often  aids,  but  its  absence  does 
not  negate  the  diagnosis. 

(C)  Acute  Nephritis.— The  pressure 
varies  greatly,  in  typhoid  fever  and 
pneumonia  there  being  no  increase  in 
tension. 


76  BLOOD   PEESSURE 

In  scarlet  fever,  however,  there  is  a 
sharp,  sudden  rise,  often  of  50  mm.,  and  it 
is  a  valuable  aid  in  the  diagnosis. 

(D)  Uremia. — Here  blood-pressure  runs 
parallel  with  the  symptoms,  maximum 
pressure  being  very  high,  in  some  cases 
290  mm.  Hg. 

Pressure  falls  with  the  alleviation  of  the 
symptoms  as  a  general  rule,  though  it  may 
fall  before  fatal  termination,  due  to  fail- 
ure of  the  heart. 

Obstetrics  and  Eclampsia,  etc.— Most 
authorities  agree  that  at  the  end  of  preg- 
nancy there  is  normally  a  rise  in  systolic 
blood-pressure  (10-15  mm.  Hg)  with  lit- 
tle change  in  the  diastolic  pressure;  al- 
though Starling,  who  reported  the  results 
of  cases  over  a  five-year  period,  believes 
the  blood-pressure  remains  normal. 

A  fact  recognized  by  all  authorities  is 
that  the  toxemia  of  pregnancy  in  the  lat- 
ter months  is  accompanied  by  a  rising 
blood-pressure,  and  that  it  is  often  present 
some  time  before  any  other  signs  or  symp- 
toms. 


IN   GENERAL   PRACTICE        77 

In  pregnancy  the  following  figures  liave 
been  given: 


Normal  cases — 

Starling — Systolic  pressure   110-120  mm.  Hg 

J.   C.   Hirst — Systolic  pressure  up  to 

seven  and  one-half  months 118  mm.  Hg 

Systolic  pressure  mid.  last  month..        124  mm.  Hg 


The  whole  subject  is  well  summarized  in 
a  paper  by  Dr.  J.  C.  Hirst,  in  which  he 
says: 

**1.  Normal  blood-pressure  in  the  non- 
pregnant is  112  mm. 

**2.  Normal  blood-pressure  in  the 
healthy  pregnant  is  118  mm.  In  the  last 
month  slightly  higher. 

**3.  Blood-pressure  in  toxemia  in  the 
first  half  of  pregnancy  associated  with 
pernicious  vomiting  is  invariably  low. 

**4.  Blood-pressure  in  the  toxemias  in 
the  latter  half  of  pregnancy  associated 
with  albuminuria  and  eclampsia  invaria- 
bly high. 

**5.  High  and  rising  blood-pressure  is  an 
invariable  and  early,   often  the  earliest, 


78  BLOOD   PKESSURE 

sign  of  toxemia  in  the  latter  half  of  preg- 
nancy. 

*'6.  Upon  rupture  of  the  membranes 
there  is  an  immediate  fall  of  pressure  60- 
90  mm.  This  fall  is  temporary  only,  but 
is  attended  with  marked  relief  in  the  head- 
ache and  epigastric  pain  these  patients  so 
often  complain  of. 

*^  Relief  lasts  for  some  hours  during 
which  there  is  a  gradual  return  to  the  pre- 
vious level. 

**7.  There  is  a  second  fall,  60-90  mm., 
after  the  child  is  born.  This  again  is  tem- 
porary, and  is  15-30  mm. ;  if  the  patient 
has  not  bled  profusely,  then  the  pressure 
is  back  to  somewhere  near  the  previous 
level  before  birth. 

**8.  Usually  blood-pressure  is  high  for 
48  hours  after  birth,  then  begins  to  subside 
and  reaches  normal,  118-124  mm.,  in  seven 
to  ten  days. 

**9.  A  blood-pressure  below  125  mm. 
should  be  disregarded ;  125-150  mm.  needs 
careful  watching  and  moderate  eliminative 
treatment. 


IN   GENERAL   PRACTICE        79 

<<Over  150  mm.  needs  active  eliminative 
treatment,  and  probably  will,  especially  if 
there  is  a  tendency  to  climb  liiglier,  require 
induction  of  premature  labor." 

Starling,  in  treatment,  advocates  before 
using  more  drastic  methods :  Rest  in  bed 
on  a  carbohydrate  and  milk  diet,  with  one 
teaspoonful  of  bicarbonate  of  soda  four 
times  a  day,  with  four  pints  of  liquid  and 
thyroid  extract  in  sthenic  cases. 

The  blood-pressure  remains  high  after 
delivery  and  the  relief  of  toxemic  symp- 
toms, whenever  there  has  been  a  previous 
nephritis.  Hypotension  also  is  important 
after,  delivery,  in  relation  to  the  question 
of  hemorrhage  and  shock,  being  markedly 
lowered  in  both  conditions.  This  is  espe- 
cially important  in  relation  to  treatment. 
The  question  of  whether  the  pressure  is 
stationary,  progressively  rising  or  falling, 
and  its  relation  to  treatment  are  of  more 
importance  than  absolute  figures,  though 
the  latter  serve  as  a  good  guide. 

Plumbism.— Both  acute  and  chronic 
cases  show  a  well-marked  high  tension. 


80  BLOOD  PEESSURE 

In  doubtful  cases,  where  there  is  high 
tension,  examine  for  signs  of  plumbism. 

Treatment  of  Hypertension.— Hyperten- 
sion is  a  symptom  and  not  a  disease,  and 
its  treatment,  like  that  of  any  other  symp- 
tom, is  that  directed  to  the  cause.  At  the 
outset  it  should  be  clearly  borne  in  mind 
that  in  a  large  number  of  cases  hyperten- 
sion is  a  necessary  compensatory  process 
in  order  to  maintain  a  correct  cardiovas- 
cular equilibrium.  This  is  especially  true 
in  advanced  cases  where  marked  vascular 
changes  have  taken  place  and  the  condition 
is  beyond  the  spastic  stage.  Where  the 
causation  of  hypertension  cannot  be  re- 
moved we  often,  instead  of  lowering  blood- 
pressure,  best  conserve  the  interests  of 
our  patients  by  maintaining  the  ten- 
sion. 

Prophylaxis.— Prophylaxis  is  most  im- 
portant and  will  become  more  and  more 
frequently  used  as  the  routine  taking  of 
blood-pressure  becomes  more  prevalent. 

Many  cases  of  hypertension  will  be 
found  before  there  are  any  symptoms  at- 


IN   GENERAL   PRACTICE        81 

tributable  to  it  or  any  organic  changes  in 
the  blood-vascular  system.  In  other 
words,  it  will  be  discovered  in  the  spastic 
stage. 

Dr.  L.  G.  Visscher,  in  a  paper  on  the 
treatment  of  chronic  hypertension,  gives  a 
very  good  presentation  of  this  subject.  He 
says  in  substance: 

We  should  warn  our  patients  against  a 
chronic  overindulgence  in  food,  more  espe- 
cially in  food  having  a  large  nuclein  con- 
tent which  tends  to  form  excessive  purin 
compounds,  which  are  marked  elevators  of 
blood-pressure,  e.  g.,  meats,  kidneys,  liver, 
sweet-breads,  caviar,  cured  meat,  sausage, 
gravies,  old  cheese  broth,  mushrooms, 
peas,  veal,  etc. 

Equally  important  is  to  emphasize 
proper  mastication  and  slow  eating;  the 
avoidance  of  excessive  muscular  exercise, 
without  gradual  training,  but  the  impor- 
tance of  moderate  exercise  in  the  open  air ; 
the  avoidance  of  late  hours  without  the 
proper  amount  of  sleep,  and  the  overindul- 
gence in  coffee,  tea,  tobacco,  and  alcohol; 


82  BLOOD   PEESSURE 

the  value  of  water  drinking ;  and  the  elimi- 
nation of  excessive  mental  work  and  worry 
and  the  abstinence  from  exciting  and 
highly  stimulating  amusements. 

Now,  turning  to  the  treatment  of  a  pa- 
tient who  comes  to  us  with  symptoms  of 
hypertension,  or  one  in  whom  we  discover 
the  condition  during  routine  examination, 
certain  factors  are  of  great  importance  in 
determining  the  treatment  to  be  given: 

1.  Age  of  the  patient.  Those  around 
forty  years  are  treated  quite  differently 
from  those  of  sixty. 

2.  Is  the  hypertension  part  of  an  acute 
process  or  a  chronic  one?  If  chronic,  how 
extensive  are  the  sclerotic  changes? 

3.  Is  the  blood-pressure  sufficiently  high 
to  cause  immediate  danger  of  apoplexy  or 
cardiac  dilatation? 

4.  What  is  the  condition  of  the  myocar- 
dium? 

5.  Is  the  hypertension  primary  or  sec- 
ondary? 

All  these  questions  cannot  be  answered 
at  once,  and  some  can  only  be  determined 


IN   GENERAL  PRACTICE        83 

after  long  study,  but  there  are  certain  lines 
of  treatment  which  we  can  institute  at 
once,  which  aid  us  in  a  diagnosis  and  at 
the  same  time  benefit  our  patient. 

Here  I  shall  again  quote  in  substance 
from  Dr.  L.  G.  Visscher : 

Our  first  task  is  to  determine  the  food 
intake  of  our  patient  and  limit  it  as  to 
quantity,  but  more  especially  as  to  the 
nuclein  foods  mentioned  under  prophy- 
laxis, for  the  formation  of  purin  com- 
pounds produces  marked  hypertension. 
Here  it  is  important  to  estimate  the  in- 
dican,  urea,  and  acidity  of  the  urine  in 
order  to  determine  the  proteid  tolerance 
of  these  cases.  An  excessive  nuclein  food 
causes  an  acidosis  and  the  carbonic  acid 
is  retained  in  the  blood  and  not  given  off 
so  freely  from  the  lungs.  As  carbonic  acid 
has  marked  pressor  effects,  the  tension  is 
elevated.  By  cutting  down  nuclein  foods 
to  their  point  of  tolerance  and  giving 
plenty  of  vegetables  and  fruit  the  acidosis 
is  prevented  and  the  tension  lowered. 
Care  must  be  used  in  old  subjects  as  they 


84  BLOOD   PRESSURE 

are  accustomed  to  and  need  a  higher  pro- 
teid  food;  dieting  in  these  cases  often 
causes  cardiac  weakness  and  severe  symp- 
toms. 

As  Dr.  Visscher  says: 

*'One  routine  way  is  the  administration 
of  alkaline  laxatives,  since  it  has  been 
demonstrated  that  alkalinity  of  the  intes- 
tinal contents  increases  putrefaction  and 
since  the  products  of  this  process  have 
high  pressor  qualities,  it  is  better  to  give 
non-alkaline  laxatives,  when  indican  is 
abundant  in  the  urine. 

^'I  have  found  it  of  distinct  benefit  in 
cases  in  which  introduction  by  mouth  of 
alkali  increases  flatulency  to  administer  it 
by  rectum  once  or  twice  a  day. 

*'A  frequent  coeffect  of  laxative  medica- 
tion is  the  hurrying  of  albumoses  into  the 
realm  of  the  colon  bacillus,  which  thrives 
on  albumoses  and  does  not  subsist  on  pep- 
tones ;  therefore  it  is  our  task  to  give  laxa- 
tives early  before  breakfast  or  well  after 
the  height  of  digestion. 

'*Next    it    is    important    to    determine 


IN   GENERAL   PRACTICE        85 

whether  we  are  dealing  with  a  case  of 
hypertension  with  increased  intraabdom- 
inal tension.  This  condition  is  clinically 
manifested  by:  Slight  dyspnea,  moderate 
hypertension,  aching  limbs,  torpid  liver 
and  catarrhal  gastritis." 

The  causes  are: 

**Abmidant  food. 

*^  Gorged  liver. 

* '  Chronic  loading  of  a  distended  colon. 

*^Gas  in  the  stomach  and  colon. 

^' Omental  fat. '^ 

These  conditions  he  treats  by  regulation 
of  the  diet,  use  of  laxatives  in  the  morn- 
ing, warm  enema  in  the  evening,  carmina- 
tives and  massage  of  the  abdomen. 

**In  dealing  with  general  obesity  or 
more  local  embonpoint,  a  good  deal  of  cau- 
tion is  needed;  not  so  much  at  the  disap- 
pearance of  fat  do  we  aim  as  at  the  timely 
prevention  of  its  formation.  When  the 
abdominal  parietes  have  first  been  com- 
fortably filled  for  years,  and  thereafter 
uncomfortably  stretched  for  some  more 
years,     the    intra-abdominal     circulation 


86  BLOOD   PRESSURE 

adapting  itself  more  or  less  to  it  in  the 
meanwhile,  what  will  happen  by  energetic 
under-dieting  and  massaging?  Though 
the  diaphragm  will  be  greatly  freed  in  its 
excursions,  the  flabby  abdominal  wall  will 
give  insufficient  support  and  a  tendency  to 
allow  intra-abdominal  pressure  will  be 
manifest  with  a  hindrance  to  expiratory 
excursion.  This  low  intra-abdominal  ten- 
sion, accompanied  by  a  feeling  of  exhaus- 
tion and  early  fatigue  in  our  advanced  hy- 
perpietics,  is  a  far  more  difficult  matter  to 
deal  with.  The  inferior  cava  output  is  re- 
tarded and  the  venous  splanchnic  area  re- 
mains gorged,  with  flatulence  and  indiges- 
tion as  a  result,  only  compensated  for  by  a 
rise  of  pressure  in  the  splanchnic  arteries, 
thereby  throwing  back  the  work  on  the  al- 
ready overburdened  heart.  So,  in  a  meas- 
ure, we  should  endeavor,  in  spite  of 
hypertension,  to  overfeed  our  lean  pa- 
tients, not  forgetting  that  many  thin  peo- 
ple, when  hyperpietic.  are  often  big  eaters 
and  mysteriously  powerful  alcohol  ab- 
sorbers." 


IN   GENERAL   PEACTICE        87 

Then  taking  up  exercise,  bathing,  and 
sleep,  he  says: 

** Within  bounds  of  reason  an  ample 
amount  of  outdoor  exercise  is  beneficial.  I 
emjDhasize  a  one  or  two-mile  constitu- 
tional before  retiring,  depending  on  the 
heart's  tonicity  and  reserve  force. 

^'Warm  bathing  is  very  beneficial,  both 
morning  and  evening,  with  a  cold  sponge 
or  shower  thereafter. 

^'As  to  hours  of  sleep,  it  should  be  bet- 
ter understood  that  carbonic  acid  is  of  high 
pressor  power,  that  sleep  in  ill-ventilated 
rooms  will  interfere  with  metabolism  dur- 
ing one-third  of  our  lifetime,  a  time  addi- 
tionally spent  in  the  digestion  and  assimi- 
lation of  the  heaviest  meal  of  the  day. 
Invariably,  for  reasons  already  given,  peo- 
ple with  hypertension  would  better  eat 
light  evening  meals,  with  ease  thereafter 
for  a  few  hours,  then  take  a  moderate 
amount  of  physical  exercise,  a  warm  bath, 
perhaps  a  warm  enema,  and  sleep  in  a 
warm  bed  with  the  windows  wide  open.'' 
If  having  tried  the  methods  just  mentioned 


88  BLOOD   PRESSURE 

the  desired  result  is  not  obtained  we  may 
then  turn  to  various  modes  of  treatment, 
as  drugs,  etc. 

The  benefit  to  be  derived  is  in  propor- 
tion to  the  amount  of  vascular  spasm  pres- 
ent, it  being  remembered  that  even  in 
markedly  sclerotic  cases  there  is  usually 
some  arterial  spasm  present. 

The  first  to  be  mentioned  are  the  iodides. 
Dr.  J.  Mackenzie  states  that  nitrites  are 
of  little  avail,  as  their  action  is  too  transi- 
tory. In  cases  of  high  tension  with  dis- 
comfort, as  pain  and  tightness  across  the 
chest,  he  uses  potassium  iodide  in  five- 
grain  doses  four  times  a  day,  and  finds 
that  it  often  relieves  the  symptoms,  but 
quite  often  does  not  lower  the  tension, 
though  marked  benefit  is  shown.  (One 
point  is  to  be  borne  in  mind,  careful  ob- 
servation of  the  patient  to  see  that  he  does 
not  develop  thyroidism  from  the  iodine 
given.) 

Dr.  Mackenzie  also  advocates  chloral 
hydrate  given  in  five-grain  doses  two  to 
three  times  a  day,  as  well  as  in  larger 


IN   GENERAL   PRACTICE        89 

doses  to  produce  sleep.  This  is  especially 
beneficial  in  cases  of  angina  pectoris. 

When  there  is  a  marked  arterioscler- 
osis very  little  can  be  done  to  reduce  ten- 
sion ;  the  only  means  that  would  produce  a 
marked  effect  is  by  bleeding  the  patient, 
but  the  result  would  be  temporary,  called 
for  only  when  there  was  danger  of  apo- 
plexy or  dilatation  of  the  heart.  Many  of 
these  cases,  however,  can  be  much  bene- 
fited by  proper  hygiene  to  eliminate  what 
spastic  condition  is  still  present  and 
further  can  be  made  comfortable  by  small 
doses  of  the  iodides.  The  iodides  are  of 
especial  value  in  sclerotic  cases  due  to 
syphilis. 

Cases  of  psychic  hypertension  from 
mental  work  and  worry,  in  addition  to  the 
regulation  of  diet,  exercise,  etc.,  are  often 
greatly  benefited  if  put  on  fairly  large 
doses  of  bromides  for  a  week  or  so  and 
also  if  given  chloral,  medinal,  veronal,  etc., 
to  produce  sleep.  In  addition  a  twenty- 
minute  rest  after  meals  will  be  found  very 
beneficial. 


90  BLOOD   PRESSURE 

In  senile  hearts  with  hypertension  it  is 
of  great  value  to  give  digitalis,  combined 
with  a  nitrite  or  iodide,  as  in  these  cases 
the  high  tension  is  the  result  of  a  venous 
stasis  and  a  better  action  of  the  heart  re- 
lieves the  symptoms  and  lowers  the  ten- 
sion. 

In  very  marked  cases  of  hypertension 
sometimes  the  use  of  absolute  rest,  mas- 
sage and  a  milk  diet  will  produce  a  good 
result;  in  many  a  reduction  in  pressure 
may  be  very  rapidly  attained  by  the  use  of 
an  exclusive  cereal  diet  (cooked  cereals), 
farina,  cream  of  wheat,  grits,  rice,  etc.,  es- 
pecially where  there  is  much  intestinal  fer- 
mentation and  an  acidosis  present. 

Here  it  might  be  well  to  mention  the  fact 
•that  in  some  cases  it  is  beneficial  to  limit 
the  amount  of  the  salt  intake  as  sodium 
chloride  causes  vasomotor  spasm  and  is 
hard  to  eliminate. 

In  the  toxic  group  of  cases  active  pur- 
gation with  blue  mass  or  calomel  and  the 
use  of  hot-air  baths  are  most  effective. 

Acute  toxic  cases  associated  with  dila- 


IN   GENERAL   PRACTICE        91 

tation  of  the  heart  are  best  treated  by 
venesection,  the  amount  being  determined 
by  the  sphygmomanometer  readings. 

In  the  hypertension  of  the  toxemia  of 
pregnancy  aconite  in  two-drop  doses  is 
often  efficient  and  does  not  harm  the 
heart,  but  should  not  be  used  in  other 
conditions  (for  further  treatment  see  Ob- 
stetrics). 

Aside  from  the  use  of  general  measures 
given  above,  Sir  Lauder  Brunton  advo- 
cates the  use  of  blue  mass  or  calomel  rou- 
tinely twice  a  week  or  even  on  alternate 
nights,  followed  by  a  saline  in  the  morn- 
ing, and  also  advises  patients  to  carry 
nitroglycerine  tablets  with  them,  and 
should  any  pain  in  the  chest  develop  take 
them  at  once.  He  also  gives  small 
doses  of  potassium  iodide  where  sclerotic 
changes  are  evident  in  the  peripheral  ves- 
sels. 

When  these  means  of  treatment  have 
failed  and  there  are  signs  of  beginning 
cerebral  trouble  it  is  necessary  to  use  the 
vasodilators  or  bleed. 


92  BLOOD   PEESSURE 

Dr.  R.  D.  Rudolph  gives  the  following 
as  to  the  vasodilators : 

Nitroglycerine,  dose  of  1-100  of  a  grain 
(action  lasts  an  honr,  tolerance  soon 
formed). 

Sodium  nitrite,  dose  of  2  grains  (action 
lasts  two  hours,  no  tolerance  acquired). 

Erythrol  tetra-nitrate,  dose  %  grain 
(action  lasts  6  hours,  tolerance  acquired). 

While  tolerance  may  not  be  acquired  in 
many  cases  from  sodium  nitrite  or  ery- 
throl tetra-nitrate,  in  many  others  there 
are  very  unpleasant  symptoms  and  a 
marked  tolerance  develops. 

The  benefit  to  be  derived  from  vaso- 
dilatation and  rapid  reduction  of  hyper- 
tension in  those  cases  it  benefits  can  be 
understood  well  by  the  evidence  brought 
out  by  Dr.  Charles  H.  Lawrence. 

^ '  Reduction  of  systolic  pressure  in  cases 
of  hypertension  by  nitrites,  venesection, 
electricity,  or  hot  air,  is  accompanied  by 
a  fall  in  diastolic  pressure  amounting,  as  a 
rule,  to  approximately  one-half  the  systolic 
fall.     Such  a  reduction  produces  a  coef- 


IN   GENERAL   PRACTICE        93 

ficient  of  pressure  more  nearly  approxi- 
mating the  normal  than  does  the  coefficient 
under  the  condition  of  hypertension. 

^^None  of  the  nitrite  group  are  efficient 
for  maintaining  a  pressure  at  a  perma- 
nently lowered  level,  as  a  tolerance  is  soon 
acquired  and  increasing  the  dose  is  apt  to 
cause  unpleasant  symptoms.'' 

We  may  also  use  thyroid  extract  in  two^ 
grain  doses,  three  times  daily. 

In  addition  to  drugs,  certain  mechan- 
ical, electrical,  and  hydrotherapeutic 
modes  of  treatment  are  sometimes  of  value, 
although  uncertain,  and  their  effects  tran- 
sitory, as  a  rule,  e.  g.. 

High  frequency  by  means  of  the  D'Ar- 
sonval  current. 

Electric  light  baths  are  often  valuable, 
stimulating  circulation  and  increasing 
metabolism,  and  thus  eliminating  much 
waste. 

Oxygen  haths  produce  a  sedative  action 
and  markedly  lower  tension,  being  of  value 
in  cases  of  psychic  hypertension  (tempera- 
ture 97  deg.  F.). 


94  BLOOD  PKESSURE 

Wet  pack  is  often  of  value  in  high  blood- 
pressure  in  neurasthenia  associated  with 
insomnia  (temperature  of  70  deg.  F.). 

In  addition  we  have  massage,  Swedish 
gymnastics,  and  vibrassage. 


IN   GENEEAL   PRACTICE        95 


CHAPTER  VI 

HYPOTENSIOIT 

BY  HYPOTENSION  is  meant  a  sys- 
tolic blood-pressure  of  one  hundred 
millimeters  or  lower.  Here  are  in- 
cluded a  large  number  of  cases  of  asthenia, 
etc.,  but  there  are  also  a  large  number  of 
persons  in  whom  the  hypotension  is  the  re- 
sult of  acute  infections  and  conditions  of 
sudden  onset,  in  whom  the  tension  is  low 
due  to  vasomotor  depression. 

In  blood-pressure  determinations  the  im- 
portance of  hypertension  has  been  allowed 
to  outweigh  the  value  and  significance  of 
hypotension,  so  that  in  many  cases  no  at- 
tention has  been  paid  to  a  condition  that  in 
many  cases  is  very  important  and  of  great 
significance  in  diagnosis,  prognosis,  and 
treatment. 

In  the  majority  of  cases  the  low  pres- 


96  BLOOD   PEESSUEE 

sure  is  due  more  often  to  the  depression  of 
tlie  vasomotor  center  by  toxines  than  to 
cardiac  weakness,  though  there  is  usually 
some  associated  cardiac  involvement. 

The  various  diseases  accompanied  by 
hypotension  will  be  considered  in  alpha- 
betical order,  and  where  their  treatment  is 
not  given  under  their  individual  heads  it 
will  be  taken  up  under  the  general  treat- 
ment of  hypotension. 

Acute  Cardiac  Conditions  and  Pericar- 
ditis.—Here  pressure  is  low,  the  vaso- 
motor center  being  depressed  by  the  tox- 
ines of  the  disease,  and  there  is  also  some 
weakness  of  the  heart  muscle.  The  sys- 
tolic pressure  varies  from  98  to  140 
mm. 

Chronic  Wasting  Diseases.— Cat^cer, 
Chronic  PhtJiisis,  Anemias,  etc. 

There  being  associated  brown  atrophy 
of  the  heart,  as  a  consequence  there  is  low 
blood-pressure  in  all  these  conditions. 

Systolic,  10-20  mm.  lower  than  normal. 

Diseases  with  a  Marked  Loss  of  Fluid. 
— Cholera,  diarrhea,  dysentery,  and  after 


IN   GENERAL   PRACTICE        97 

profuse  vomiting,  as  in  carcinoma  of  the 
stomach,  intestinal  obstruction,  and  peri- 
tonitis. 

In  these  conditions  there  is  a  markedly 
lowered  blood-pressnre  due  to  a  large  ex- 
tent to  the  loss  of  fluid  diminishing  the 
volume  of  the  circulating  blood.  Blood- 
pressure  determinations  are  of  great  value 
in  deciding  as  to  the  extent  of  the  condi- 
tion, as  to  the  kind  of  treatment  to  be  em- 
ployed, and  its  efficacy.  Lowering  blood- 
pressure  is  an  indication  of  impending  col- 
lapse. 

Drugs. — Alcohol, — In  small  amounts 
there  is  but  little  effect  on  blood-pressure, 
but  in  any  quantity  there  is  a  vasodilata- 
tion with  hypotension.  Long-continued  use 
leads  to  sclerotic  changes  and  higher  ten- 
sion. 

Tobacco. — Its  moderate  or  occasional 
use  produces  a  slight  rise.  When  used  to 
excess  it  produces  low  tension,  due  to  the 
toxines  in  the  tobacco. 

When  tension  is  low  from  tobacco  all  to- 
bacco must  be  discontinued,  as  a  small 


98  BLOOD   PEESSURE 

quantity  will  continue  the  low  tension  after 
it  is  once  established. 

Other  drugs  which  lower  blood-pressure 
are :  Aconite,  the  nitrites,  the  iodides,  the 
laxatives  and  purgatives,  chloral  hydrate, 
pituitary  extract,  and  thyroid  extract  (see 
treatment  of  hypertension).  Chloroform 
also  lowers  tension  (see  surgery  and  anes- 
thesia). 

Hemorrhage,  Extensive.— In  these  cases 
there  is  a  marked  drop  in  blood-pressure 
proportionate  to  the  amount  of  the  hem- 
orrhage, being  a  mechanical  result  due  to 
the  lessened  volume  of  the  blood  the  heart 
has  to  pump.  This  fall  in  pressure  is  fol- 
lowed by  a  rather  rapid  rise  to  the  normal 
level  as  soon  as  the  bleeding  point  is  se- 
cured. After  securing  the  bleeding  point 
the  pressure  is  best  restored  by  an  intra- 
venous injection  of  saline. 

Acute  Infectious  Diseases.— In  all  in- 
fectious diseases,  except  meningitis,  there 
is  a  fall  in  blood-pressure,  due  mainly  to 
vasomotor  depression  or  paralysis,  from 
the  toxines  present,  but  also  to  a  lesser  de- 


IN   GENERAL  PRACTICE        99 

gree  to  the  damaged  heart  muscle,  from 
the  same  cause. 

The  systolic  pressure  usually  falls  be- 
low one  hundred  millimeters  of  mercury, 
and  remains  low  during  the  acute  process 
of  the  disease,  and  in  some  cases  late  in 
the  convalescence. 

The  acute  infectious  diseases  in  which 
blood-pressure  has  a  special  significance 
will  now  be  considered  in  alphabetical 
order. 

Diphtheria, — As  might  be  expected  in  a 
disease  marked  by  such  severe  toxemia  the 
blood-pressure  is  often  very  low.  Blood- 
pressure  values  aid  materially  in  deciding 
what  stimulation,  if  any,  is  required,  and 
are  of  great  value  in  determining  the  con- 
dition of  the  myocardium  during  convales- 
cence and  deciding  when  to  allow  any 
physical  exertion.  In  a  condition  where 
the  danger  of  cardiac  failure  is  so  great 
any  accurate  means  of  determining  the  ex- 
act condition  present  is  of  inestimable 
value. 

Pneumonia, — Here  there    may    not   be 


100  BLOOD  PEESSURE 

much  change  in  the  blood-pressure,  though, 
as  the  disease  progresses,  there  is  a  ten- 
dency for  it  to  lower. 

Hirschfelder — Systolic   110-130  mm.  Hg 

Diastolic     90-130  mm.  Hg. 

Pulse  rate   120 

Gibson  of  Edinburgh  made  a  general 
rule  which  seems  to  work  out  well  in  pa- 
tients who  are  not  alcoholics,  but  does  not 
apply  to  this  class  of  patients.  The  rule  is 
as  follows :  When  the  systolic  pressure  ex- 
pressed in  mm.  of  Hg  is  higher  than  the 
pulse  rate  expressed  in  beats  per  minute, 
the  condition  of  the  patient  is  good.  When 
the  systolic  pressure  expressed  in  mm.  Hg 
is  lower  than  the  pulse  rate  per  minute,  the 
condition  is  serious. 

Dr.  Alexander  Lambert,  in  a  recent  ar- 
ticle, called  attention  to  the  fact  that  the 
blood-pressure  varies  greatly  in  pneu- 
monia, but  that  it  is  of  the  greatest  value 
in  determining  whether  the  condition  pres- 
ent is  one  of  vasomotor  paralysis,  due  to 
toxines,  in  which  case  the  blood-pressure 


IN   GENEEAL   PRACTICE      101 

will  be  found  to  be  low ;  or  whether  the  pa- 
tient is  suffering  from  high  tension,  with 
cardiac  failure  imminent. 

About  one-half  the  cases  die  of  vaso- 
motor paralysis,  the  other  half  from  fail- 
ure of  the  heart.  In  the  one,  adrenalin, 
camphor,  strychnia,  and  digitalis  are  in- 
dicated; in  the  other,  relief  of  the  high 
tension  with  vasodilators  or  bleeding  is  in- 
dicated. 

The  matter  is  very  tersely  expressed  by 
Dr.  H.  A.  Hare  when  he  says : 

*^If  the  vessels  be  at  fault  the  difference 
between  diastolic  and  systolic  pressure 
will  be  marked,  the  heart,  if  strong,  send- 
ing out  a  forcible  wave  of  blood  in  an  en- 
deavor to  fill  the  blood  paths.  On  the 
other  hand,  if  the  pressure  be  low  from  a 
failing  heart,  there  will  be  little  difference 
between  diastolic  and  systolic  pressure, 
for  obvious  reasons.'' 

The  blood-pressure  is  important  not  only 
in  the  beginning  for  diagnostic  purposes, 
but  also  throughout  the  course  of  the  dis- 
ease in  order  to  determine  the  treatment 


102  BLOOD   PEESSUEE 

required,  and,  if  drugs  are  indicated,  to 
regulate  their  dosage  and  the  duration  of 
their  use. 

Rheumatism,  Acute  Articular. — Here 
the  blood-pressure  is  al^o  low  and  the 
readings  are  of  main  importance  in  de- 
termining the  treatment  and  progress  of 
the  case  during  convalescence. 

Scarlet  Fever. — Hypotension  is  present 
in  the  ordinary  uncomplicated  case,  but 
should  nephritis  develop  during  the  course 
of  the  disease  there  is  a  sharp,  marked  rise 
in  tension.  This  does  not  take  place  in 
other  infectious  diseases. 

Typhoid  Fever. — Here  we  have  one  of 
the  lowest  pressures  occurring  in  diseases. 

Often  systolic   .100-120  mm.  Hg 

diastolic    60-90    mm.  Hg 

The  systolic  pressure  has  been  as  low  as 
75  mm.  Hg. 

The  fall  in  pressure  is  gradual,  and 
takes  place  progressively  (Janeway),  e.  g. 


IN   GENERAL   PRACTICE      103 

First  week — Systolic  115  mm.  Hg 

Second    week — Systolic    106  mm.  Hg 

Third  week— Systolic    102  mm.  Hg 

Fourth  week— Systolic   98  mm.  Hg 

Fifth   week— Systolic    96  mm.  Hg 

Here  the  value  of  routine  blood-pressure 
observations  is  very  great,  both  to  deter- 
mine the  effect  and  amount  of  treatment 
required,  and  also  to  be  able  to  note  the 
onset  of  complications. 

In  hemorrhage  there  is  a  sharp  sudden 
fall,  due  to  a  lessened  volume  of  blood. 

In  perforation  just  the  opposite  takes 
place,  the  irritation  of  the  peritoneum 
causing  a  reflex  vasoconstriction  and  a 
sudden  sharp  rise  in  blood-pressure. 

The  work  of  Briggs  and  Cook  showed  in 
one  case  a  rise  of  blood-pressure  hours 
before  there  were  any  other  definite  signs 
of  perforation.  The  diagnosis  was  con- 
firmed by  operation.  But  as  they  demon- 
strated, you  do  not  always  obtain  a  rise 
in  blood-pressure,  for  the  vasomotor  center 
may  be  exhausted,  in  which  case  there  will 
be  no  rise.  Therefore,  a  lack  of  rise  in 
blood-pressure  does  not  negate  other  signs, 


104  BLOOD   PRESSURE 

and  symptoms  of  perforation,  but  when 
high  pressure  is  present  it  is  reliable,  un- 
less pneumonia  develops. 

Using  blood-pressure  in  conjunction 
with  treatment  they  find : 

Baths  when  favorable  produced  a  rise  in 
blood-pressure. 

Of  the  drugs,  strychnia  and  digitalis 
were  the  best  to  combat  collapse.  When 
used  for  a  quick  result  strychnia,  gr.  1-10- 
1-20  hypo.,  was  given,  and  the  resulting 
rise  in  blood-pressure  was  maintained  for 
an  hour  or  so.  When  the  pressure  begins 
to  fall,  it  may  be  maintained  by  a  smaller 
dose. 

Digitalin  hypo,  was  more  certain  than 
strychnia,  with  an  initial  dose  of  gr.  1-10 ; 
its  action  taking  place  earlier,  though  not 
so  long  continued.  It  often  gave  a  rise 
when  strychnia  failed.  Permanency  of 
results  may  be  obtained  by  combining  the 
two. 

Alcohol  was  of  no  value  as  a  stimulant, 
but  lowered  pressure,  and  was  of  benefit 
solely  as  an  alternative. 


IN   GENEEAL   PEACTICE      105 

Thayer  found,  as  a  sequence  of  typhoid 
fever,  a  rather  marked  hypertension  some 
years  after  the  original  attack. 

Acute  Infections  of  Children. -Here 
Briggs  and  Cook  found  blood-pressure  de- 
terminations of  the  greatest  value  in  prog- 
nosis and  treatment.  If  pressure  is  fall- 
ing there  is  danger  of  collapse,  and  it  is  an 
indication  for  active  stimulation. 

They  concluded  that  a  systolic  pressure 
of  60  mm.  during  the  first  year,  and  80  mm. 
in  older  children,  were  the  danger  lines, 
calling  for  active  stimulation. 

Treatment. — In  collapse  with  cyanosis 
they  used  a  mustard  bath,  and  found  that 
strychnia  and  digitalis  were  the  most  re- 
liable drugs. 

Prognosis. — A  short-lived  response  to 
treatment  with  a  renewed  fall  is  a  bad 

sign. 

Neurological  Conditions.— (a)  Alco- 
holic  Delirium.—ReTe  pressure  is  lowered 
30-40  per  cent.,  therefore  we  must  use  care 
in  the  employment  of  hot  packs  to  quiet 
these  patients,  as  we  may  cause  collapse. 


•106  BLOOD   PEESSURE 

(b)  Insomnia  may  be  associated  with 
either  one  of  two  conditions : 

1.  High  tension  (systolic,  130-150  mm.). 

2.  Without  high  tension. 

In  the  first  vasodilators  act  as  hypnotics 
and  are  indicated ;  sleep  takes  place  as  the 
pressure  falls. 

In  the  second  class  sulphonal,  trional, 
and  similar  drugs  are  more  effec- 
tive. 

(c)  Acute  Mania. — Here  blood-pressure 
is  low,  and  after  an  attack  lower  still,  due 
to  exhaustion. 

(d)  Melancholia  elevates  blood-pres- 
sure in  proportion  to  the  symptoms,  and  is 
relieved  by  vasodilators,  improvement  oc- 
curring coincidently  with  the  lowering  of 
pressure. 

(e)  Neurasthenia,  Hysteria,  etc. — Pres- 
sure here  is  variable,  but  becomes  high 
readily,  owing  to  the  nervous  stimulation 
of  the  vasomotor  center. 

(f )  General  Paresis. — Here  in  the  early 
stage  blood-pressure  is  normal,  while  in 
the  late  it  is  low. 


IN   GENERAL   PRACTICE      107 

(g)  Trifacial  neuralgia  is  accompanied 
by  a  high  blood-pressure. 

Phthisis.— Here  we  usually  find  a  low 
systolic  pressure;  systolic,  90-100  mm., 
though  it  may  vary  between  80  and  120 
mm. 

Blood-pressure  from  the  standpoint  of 
prognosis  and  treatment  is  of  considerable 
value,  though,  as  to  diagnosis,  there  is  a 
marked  difference  of  opinion,  many  think- 
ing it  of  doubtful  value  before  physical 
signs  have  developed. 

Oiven  a  patient  with  tuberculosis  a  fall- 
ing blood-pressure  is  a  bad  sign,  while  a 
rising  blood-pressure  toward  the  normal  is 
equally  favorable. 

When  the  blood-pressure  has  reached 
the  normal,  and  remained  there,  we  may 
feel  pretty  confident  our  case  is  well;  so 
that  in  supposedly  cured  cases  it  is  impor- 
tant to  take  the  blood-pressure  observa- 
tions to  determine  whether  there  is  any  re- 
currence of  the  disease. 

Given  a  patient  with  a  persistent  low 
blood-pressure,  always  consider  the  proba- 


108  BLOOD   PEESSURE 

bility  of  tuberculosis  very  seriously,  espe- 
cially where  other  causes  for  the  low  ten- 
sion cannot  be  determined. 

Lauder  Brunton  regards  low  tension  as 
due  usually  to :  * 

1.  Beginning  phthisis. 

2.  Excessive  smoking;  further  stating 
that  where  smoking  can  be  excluded,  al- 
ways examine  the  lungs  carefully  for  tu- 
berculosis. 

Dr.  Haven  Emerson  warns  us  that  per- 
sistent low  tension  should  put  us  on  our 
guard  to  prevent  tuberculosis,  especially 
where  the  patient  is  under  unhygienic  con- 
ditions. (See  Altitude  for  effect  in 
Phthisis.) 

Shock  and  Collapse.— Here  we  have  a 
very  marked  and  dangerous  fall  in  blood- 
pressure,  due  to  vasodilatation,  from  per- 
ipheral nerve  stimuli  to  the  vasomotor 
center.  Henderson  claims  the  vasomotor 
depression  is  due  to  overaeration,  and  lack 
of  carbon  dioxide  to  stimulate  the  center. 
At  times  the  systolic  pressure  has  been  as 
low  as  40-60  mm. 


IN   GENEEAL   PRACTICE      109 

Cook  and  Briggs  proved  that  the  vaso- 
motor center  was  not  exhausted,  for,  by 
the  use  of  strychnia  and  digitalis,  they 
were  often  able  to  save  apparently  hope- 
less cases;  that  adrenalin  intravenously 
will  raise  the  pressure,  but  that  its  action 
is  fugacious;  that  an  intravenous  saline 
injection  is  of  no  value  to  raise  pressure 
unless  adrenalin  is  added;  and  that  %  to 
%  gr.  of  cocaine  hypo,  will  give  an  almost 
immediate  rise  of  blood-pressure  (10-20 
mm.)  and  maintained  from  one  to  three 
hours. 

SyphiHs.— There  is  a  hypotension  dur- 
ing the  acute  stages  due  to  the  toxemia  of 
the  disease. 

Tabes  Dorsalis.— Pal  concluded  that, 
with  the  lightning  pains,  there  was  a 
marked  fall  in  blood-pressure;  in  contra- 
distinction to  gastric  crises,  where  there 
was  an  enormous  rise.  He  assumed  that 
as  there  was  marked  hypertension  the 
splanchnics  must  be  involved,  and  advised 
the  use  of  chloral  to  relieve  the  condition 


110  BLOOD   PKESSUKE 

on  account  of  its  blood-pressure-lowering 
qualities. 

The  association  of  lugh  tension  with 
gastric  crises  aids  somewhat  in  a  differen- 
tial diagnosis,  as  there  are  only  two  other 
conditions  of  pain  in  the  abdomen  with 
high  tension:  (1)  lead  colic,  (2)  angina 
abdominalis  of  arteriosclerosis. 

Treatment  of  Hypotension. — (1)  Gen- 
eral hygiene  and  tonics. 

2.  Hydrotherapy  is  of  some  value,  e.  g., 
Needle  bath,  graduated  from  warm  to  cold. 
Vischy  bath. 

3.  Massage. 

4.  Exercise  when  moderate  and  grad- 
uated to  the  needs  of  the  individual. 

5.  Laxatives  are  of  benefit  where  low 
tension  is  associated  with  constipation. 


IN   GENEEAL  PRACTICE      111 


CHAPTER  VII 

SURGEKY  AND  ANESTHESIA 

SURGERY  AND  ANESTHESIA.- 
Anesthesia. — Ether  increases  the 
blood-pressure  first  reflexly  from  the 
irritation  of  the  mucous  membrane.  Dur- 
ing the  second  stage  the  pressure  also 
rises,  owing  to  the  muscular  activity. 

In  deep  anesthesia  the  pressure  level 
falls  to  just  above  the  normal. 

Nitrous  Oxide. — Here  there  is  a  rise  of 
pressure  due  partly  to  asphyxia.  When 
used  with  ether  there  is  an  initial  rise,  but 
the  second  increase  of  pressure  is  elimi- 
nated, because  the  stage  of  muscular  ac- 
tivity is  avoided. 

C/i^oro/orm.— Blood-pressure  falls  from 
the  start,  and  remains  low,  except  in  preg- 
nancy. 


112  BLOOD   PEESSUEE 

If,  during  anesthesia,  shock  or  collapse 
is  imminent  there  is  a  marked  falling 
blood-pressure,  before  other  signs  are 
manifest ;  hence  the  value  of  taking  blood- 
pressure  readings  every  five  minutes  dur- 
ing the  administration  of  an  anesthetic. 
If  pressure  falls  correct  any  faulty  admin- 
istration of  anesthetic,  and,  if  the  pressure 
then  rises,  proceed.  If  the  pressure  con- 
tinues to  fall,  or  remains  at  a  dangerous 
level,  use  active  measures,  and  terminate 
operative  procedure  as  rapidly  as  pos- 
sible. There  is  less  shock  by  continuing 
the  ether  than  to  allow  the  patient  to  come 
out,  and  renew  the  anesthetic.  With  a 
dangerous  fall  in  blood-pressure  while; 
Using  chloroform,  withdraw  the  anesthetic 
at  once. 

Spinal  Anesthesia  (cocaine), — You  may 
have  a  dangerous  fall  due  to  paralysis  of 
the  upper  dorsal  region. 

Operative  Procedure, — Cutting  or  ma- 
nipulative procedures  cause  a  transitory 
rise  in  blood-pressure  of  about  10  mm.  due 
to  the  pain  impulses  conveyed  to  the  vase- 


IN   GENERAL   PRACTICE      113 

motor  center;  it  may  rise  again,  remain 
low,  or  fall  further  to  shock.  If  cocaine  is 
injected  into  the  nerve  trunks  during  an- 
esthesia there  is  less  danger  of  shock. 

By  blood-pressure  determinations  we 
have  the  most  accurate  means  not  only  of 
determining  shock,  but  also  its  extent  and 
reaction  to  treatment.  The  blood-pressure 
readings  should  be  taken  routinely,  not 
only  during  the  operation,  but  also  before 
and  after.  Before  operation  often  a  case 
has  a  high  tension,  which  might  become 
dangerous  if  an  anesthetic  were  adminis- 
tered, unless  it  is  lowered  by  preparatory 
treatment.  After  operation  routine  ob- 
servations are  of  value  in  determining  the 
onset  of  shock  or  hemorrhage. 

In  addition,  in  pleural  and  peritoneal  ef- 
fusions, there  is  a  rise  of  blood-pressure. 
Aspiration  produces  a  fall,  which  can  be 
determined  by  blood-pressure  examina- 
tions and  the  aspiration  stopped  if  the  fall 
becomes  dangerous. 

In  a  recent  article,  *^  Estimation  of  Vital 
Resistance  of  Patient  with  Reference  to 


114  BLOOD   PRESSUEE 

Possibility  of  Recovery,'^  Dr.  Joseph  C. 
Bloodgood  says : 

^'For  the  estimation  of  the  factors  of 
safety  during  operation  and  the  condition 
of  the  patient  directly  after  operation,  it 
is  my  opinion  that  the  blood-pressure  ap- 
paratus is  the  most  important. 

*  ^  In  the  last  year  I  have  attempted  to  re- 
cord blood-pressure  measurements  before, 
after,  and  during  all  operations,  with  the 
result  that  I  have  found  these  records  the 
most  important  method  of  estimating  the 
exact  condition  of  the  patient.'' 

Under  treatment  during  operation  he 
says: 

^*  During  the  last  year  I  have  paid  con- 
siderable attention  to  the  routine  blood- 
pressure  records,  and  at  the  present  time 
I  am  getting  the  impression  that  the  blood- 
pressure  will  warn  the  surgeon  of  the  dan- 
ger line  before  the  pulse  or  respiration. 
My  respect  for  the  blood-pressure  record 
is  increasing  daily,  and  I  would  urge  all 
surgeons  to  use  it  in  extraordinary  opera- 
tions and  handicapped  patients.     But  to 


IN   GENERAL   PRACTICE      115 

learn  to  interpret  these  records,  one  must 
employ  them  at  all  operations  as  a  rou- 
tine. 

*' When  the  blood-pressure  falls  to  100  or 
lower,  it  is  time  to  stop  the  operation  and 
time  to  give  the  saline,  which  in  such  cases 
should  be  given  immediately.  I  have  had 
a  few  such  cases  with  very  happy  results. 

*  *  There  is  one  point  I  wish  to  make  clear 
which  many  surgeons  do  not  seem  to  be  fa- 
miliar with.  The  patient  seems  in  fair 
condition  at  the  end  of  the  operation,  but 
no  blood-pressure  record  is  taken.  He  is 
lifted  to  the  stretcher,  carried  to  his  room, 
and  when  put  to  bed  is  found  to  be  in  col- 
lapse requiring  hurried  treatment.  This 
can  be  avoided  in  most  cases  if,  after  the 
operation  is  finished  and  the  bandage  ad- 
justed, a  blood-pressure  record  is  taken. 
If  the  record  is  much  lower  than  that 
taken  at  the  end  of  the  operation,  it  is  an 
indication  that  the  patient  should  not  be 
transported,  but  kept  quietly  on  the  table 
and  given  the  salt  solution  by  one  or  aU 
three  methods.    It  is  important  therefore 


116  BLOOD  PEESSURE 

carefully  to  investigate  the  patient  before 
he  is  lifted  from  the -operating  table  to  be 
transported,  and  to  begin  the  post-opera- 
tive saline  treatment  then  if  indicated.  I 
am  confident  that  this  will  prevent  many 
of  the  cases  of  collapse  or  sudden  vaso- 
motor failure  which  are  observed  after  the 
patient  reaches  his  bed. 

*  *  The  surgeon  must  be  familiar  with  the 
manipulations  which  produce  shock.  Noth- 
ing helps  him  more  to  estimate  this  than 
the  blood-pressure.  It  is  to  be  remem- 
bered that  anything  that  either  diminishes 
or  increases  the  blood-pressure  is  a  stimu- 
lation which  sooner  or  later  will  lead  to 
exhaustion  and  a  fall  in  blood-pressure. 
It  is  the  uniform  rate  of  the  pulse  and 
respiration  and  uniform  blood-pressure 
that  indicate  an  operation  with  the  least 
degree  of  shock.*' 


IN   GENERAL  PRACTICE      117 


CHAPTER  Vin 


UFE   INSUEANCE 


IN  LIFE-INSURANCE  examination, 
almost  all  companies  now  recognize 
blood-pressure  estimation  as  a  neces- 
sary procedure.  The  reason  for  this  is 
very  clearly  shown  in  the  statistics  from 
the  Northwestern  Life  Insurance  Com- 
pany, which  was  one  of  the  pioneers  in  tak- 
ing blood-pressure  readings  on  its  appli- 
cants. In  a  letter  to  their  examiners  they 
say: 

^^The  statistics  on  1,247  cases  at  all 
ages,  in  which  there  was  a  blood-pressure 
of  150  mm.  mercury  and  over,  show  a  mor- 
tality two  and  one-half  times  greater  than 
the  general  average  mortality  of  the  com- 
pany covering  the  same  period.  In  891  of 
these  cases  there  was  no  other  impairment 
recorded  in  the  application  when  received 


118  BLOOD   PRESSURE 

at  the  home  office.  All  these  risks  would 
have  been  granted  insurance  had  not 
blood-pressure  been  taken.  A  careful 
study  of  the  statistics  of  this  company 
demonstrates,  without  a  doubt,  that  the 
use  of  the  sphygmomanometer  is  indis- 
pensable in  our  examination  for  life  insur- 
ance. The  statistics  also  demonstrate,  in 
our  opinion,  that  the  use  of  the  sphyg- 
momanometer will  be  of  equal  value  to  the 
practitioner  in  his  general  practice,  and 
that  no  physician  should  be  without  this 
valuable  aid  in  diagnosis. 

**We  feel,  therefore,  that  it  is  not  un- 
reasonable to  require  the  examiners  of  this 
company  to  procure  an  instrument  and 
furnish  the  company  with  the  blood-pres- 
sure in  all  examinations  they  make,  regard- 
less of  the  age  or  amount  of  insurance  ap- 
plied for.  We  shall  expect,  therefore,  our 
examiners,  who  do  not  at  this  time  pos- 
sess a  sphygmomanometer  or  have  the  use 
of  one,  to  provide  themselves  with  the  in- 
strument to  enable  them  to  comply  with 
the  rules  of  the  company. '* 


IN   GENERAL   PRACTICE       119 

In  taking  blood-pressure  in  this  class  of 
cases  there  are  several  important  factors 
to  be  considered,  more  fully  discussed  in 
the  section  on  Physiological  Variations 
(see  page  40),  but  it  might  be  well  to  re- 
peat them.  It  is  often  well  to  adjust  the 
pneumatic  cuff  to  the  patients,  but  not 
take  the  pressure  reading  for  some  min- 
utes, in  the  meantime  obtaining  what  data 
is  desired  from  the  patient,  as  many  per- 
sons are  nervous  and  under  a  mental 
strain  when  being  examined.  In  this  way 
you  largely  eliminate  the  nervous  excite- 
ment and  mental  tension,  which  will  often 
raise  the  pressure  10  or  more  millimeters. 

The  cuff  should  be  adjusted  at  the  heart 
level,  the  patient  in  a  comfortable  position 
with  muscular  relaxation  and  breathing 
quietly. 

Pressure  readings  are  preferably  taken 
midway  between  meals.  Make  the  actual 
determination  as  rapidly  as  possible,  as 
prolonged  constriction  of  the  arm  ma- 
terially raises  the  tension  (do  not  take 
over  1-3  minutes). 


120  BLOOD   PEESSURE 

Make  it  a  rule  to  take  all  observations 
on  your  applicants  in  the  same  position, 
either  in  the  sitting  or  reclining  posture. 

As  mental  work  and  stimuli  markedly 
raise  the  pressure,  which  even  judicious 
treatment  during  the  examination  will  not 
always  eliminate,  if  readings  are  too  high 
without  any  apparent  organic  change,  ask 
for  a  subsequent  examination,  when  the 
patient  has  rested  and  is  free  from  excit- 
ing stimuli. 

It  is  always  best  to  obtain  several  read- 
ings and  get  an  average.  On  numerous  oc- 
casions business  men  have  been  examined 
during  their  working  hours,  and  blood- 
pressure  readings  were  found  to  be  con- 
siderably too  high,  but  the  same  men  after 
a  few  hours  rest  have  had  a  normal 
blood-pressure  and  have  been  accepted 
without  a  doubt  in  the  mind  of  the  ex- 
aminer. In  some  cases,  if  the  tension  is 
still  high  or  the  readings  are  on  the  bor- 
der line,  it  is  important  to  take  a  number 
of  readings. 

Aside  from  these   general  precautions 


IN   GENERAL   PRACTICE      121 

there  are  not  any  factors  influencing  blood- 
pressure  readings  to  any  marked  degree. 
Even  age,  whicli  has  been  greatly  empha- 
sized in  the  past,  is  not  a  great  factor. 
The  status  of  age  in  relation  to  blood- 
pressure  is  clearly  expressed  by  Dr.  Henry 
Wireman  Cook: 

*'Age  after  childhood  is  constantly  as- 
suming a  less  and  less  important  place  as 
a  factor  in  normal  blood-pressure  varia- 
tions. In  early  observations  high  blood- 
pressure  at  older  ages  was  found  of  so 
much  greater  relative  frequency  that  prac- 
tically all  observers  were  led  into  the  be- 
lief that  much  higher  blood-pressures  were 
normal  at  the  older  ages  than  is  actually 
the  case.  This  partly  rose  from  the  use  of 
a  narrow  arm-piece,  which  unduly  empha- 
sized any  increase,  but  probably  in  most 
part  the  mistake  was  due  to  the  fact  that 
the  cardiovascular  and  renal  changes  are  so 
much  more  common  after  forty-five.  Later 
and  more  accurate  observations,  however, 
showed  that  there  is  very  little  normal  in- 
crease in  the  blood-pressure  before  sixty 


122  BLOOD   PEESSUEE 

years  of  age,  and  when  a  marked  hyper- 
tension is  present  it  is  associated  with  a 
distinct  abnormality  of  tissue  function. 
Authoritative  data  on  this  subject  are 
most  convincing.'^ 

In  over  two  hundred  consecutive  blood- 
pressure  observations  Janeway  saw  145 
mm.  Hg  exceeded  only  once  or  twice,  ex- 
cept where  cause  for  hypertension  existed. 
In  routine  examinations  of  many  hundreds 
of  cases  he  never  saw  a  pressure  above  160 
mm.  in  a  normal  person — seldom  one 
above  140  mm.  (wide  arm-piece).  He  re- 
gards with  suspicion  any  pressure  over 
145  mm.  His  later  statement,  March, 
1911,  is  ^*A  blood-pressure  reading  of 
more  than  145  mm.  before  middle  life  or 
of  more  than  160  mm.  after  must  be  con- 
sidered abnormal." 

Before  closing  I  wish  to  call  attention  to 
some  aspects  of  blood-pressure  in  relation 
to  life-insurance  examination,  which  in  the 
past  have  received  very  little  attention : 

First,  the  value  in  doubtful  cases  of  the 
use  of  the  functional  test  of  the  myocar- 


IN   GENERAL  PRACTICE      123 

dium,  by  a  regulated  amount  of  exercise 
with  blood-pressure  readings  (see  Heart 
Diseases,  page  69). 

Second,  the  importance  of  routinely  tak- 
ing the  diastolic  blood-pressure  as  well  as 
the  systolic,  as   the  pulse  pressure   (dif- 
ference between  the  systolic  and  the  dias- 
tolic)  is  often  invaluable  in  determining 
the  amount  of  arteriosclerosis  present;  as 
already  has  been  described  there  are  a 
number  of  patients  in  whom  the  systolic 
pressure  is  at  the  normal  level,  but  who 
have  had  a  high  systolic  pressure  until  the 
myocardium  has  given  away  and  the  hy- 
pertension could  no  longer  be  maintained. 
Here  the  diastolic  pressure  remains  rela- 
tively high,  giving  a  small  pulse  pressure 
and  making  the  diagnosis  of  arteriosclero- 
sis, with  associated  myocarditis. 

More  attention  should  be  paid  to  hypo- 
tension, in  relation  to  tuberculosis. 

Diseases  to  consider  are:  chronic  inter- 
stitial nephritis,  cardiac  diseases,  arterio- 
sclerosis, angina  sclerosis  and  tuberculosis. 


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VisscHER,  L.  G.  Treatment  of  chronic  hyper- 
tension. Journal  of  Amer.  Med.  Associa- 
tion, December  2,  1911. 

VoYLER,    W.    J.     The   blood   pressure    during 


130  BIBLIOGEAPHY 

pregnancy  and  the  puerperium.  Amer. 
Journal  of  Obstetrics,  Vol.  LX,  1907. 

Warfield,  Louis  N.  The  oscillatory  blood  pres- 
sure phenomenon.  Interstate  Med.  Journal, 
October,  1912. 

"VYiGGERS,  C.  J.  Prognostic  significance  of  pulse 
pressure  changes  during  hemorrhage.  Arch- 
ives of  Internal  Medicine,  September,  1910. 

WooLEY,  H.  P.  Normal  variation  of  systolic 
blood  pressure.  Journal  American  Med. 
Association,  July  9,  1910. 


INDEX 

Acidosis   (with  hypertension), 

cereal  diet  in,  90. 
Aconite, 

effect  on  blood  pressure,  91. 
hypotension  from,  98. 
in  toxaemia  of  pregnancy,  91. 
Adrenalin,  hypertension  from,  58. 
in  pneumonia,  101. 
in  shock  and  collapse,  109. 
Age,  blood-pressure  variations  in,  37,  38,  121, 
Alcohol,  effect  on  blood  pressure,  97. 
hypertension  from,  97. 
hypotension  from,  97. 
in  typhoid  fever,  104. 
Alcoholic  delirium,  blood  pressure, 
readings  in,  105. 
hypotension  in,  105. 
Altitude,  effect  on  blood  pressure,  42. 
effect  on  cardiac  cases,  43. 
effect  on  phthisis,  44. 
Anaemia,  blood  pressure  in,  96. 

hypotension  in,  96. 
Aneroids,  23,  24,  25,  26. 
Ansesthesia,  blood  pressure  in.  111,  112. 
value  of  blood  pressure, 
readings  in,  112. 
Anger,  effect  on  blood  pressure,  42. 

131 


132  INDEX 

Angiosclerosis,  definition  of,  49. 

diagnostic  importance  of,  49. 
treatment  in,  49,  50. 
Angina  pectoris,  blood -pressure  readings  in,  50,  51. 
chloral  hydrate  in,  88,  89. 
diagnosis  of,  50,  51. 
symptoms  of,  50,  51. 
Aortic  regurgitation,  auscultation  method  in,  68. 

blood-pressure  readings  in,  67. 
difference     between    brachial     and 

femoral  readings  in,  68. 
diastolic  pressure  in,  68. 
hypertension  in,  67,  68. 
Apoplexy,  blood-pressure  readings  in,  73. 
cause  of  hypertension  in,  73. 
diagnostic  use  of  blood  pressure  in,  73. 
treatment  of,  73. 
Arm  bands,  location  of,  in  relation  to  blood  pressure,  40. 

width  of,  3,  17. 
Arteries,  determination  of  dilatation  of,  33. 
Arteriosclerosis,  51-56. 

blood-pressure  readings  in,  52. 

cerebral,  diagnosis  of,  54. 

diagnosis  of,  51,  52. 

factors  to  consider  in  the  diagnosis  of,  52,  53. 

hypertension  in,  when  associated  disease,  55. 

hypertension  of,  treatment  of,  89. 

iodides  in  the  treatment  of,  89,  91. 

measure  of  the  degree  of,  54. 

myocarditis  in,  55,  56. 

primary,  hypertension  relation  to,  52,  53. 

result  of  hypertension,  46,  53. 

routine  blood  pressure  to  determine  the  onset  of, 

54,  55. 
senile,  blood  pressure  in,  54. 


INDEX  133 

Arteriosclerosis,  syphilitic,  iodides  in  the  treatment  of, 

89. 
Asphyxia,  effect  on  blood  pressure,  45. 
Aspiration  of  serous  fluid,  blood  pressure  in,  113. 
Asthma  (cardiac),  hypertension  in,  68-69. 
Atropine,  effect  on  blood  pressure,  60. 
Auscultation  method,  intensity    of    sounds    and    signifi- 
cance of,  12. 
on  what  based,  13,  14. 
sounds  and  phases,  11,  12,  13. 
the  determination  of  systolic  and 
diastolic  pressure  by,  9,  10. 
Autointoxication,  56,  57. 

Baths,  electric  light  in  the  treatment  of  hypertension,  93. 
hot  air  in  treatment  of  toxic  hypertension,  90. 
oxygen,  in  the  treatment  of  hypertension,  93. 
treatment  of  hypertension,  87. 
typhoid  fever,  their  use  and  effect  on  blood  pres- 
sure, 104. 
Bendick  air  water  blood-pressure  apparatus,  23. 
Bibliography,  126,  127. 
Bleeding,  in  acute  toxic  hypertension,  91,  92. 

in  hypertension,  apoplexy  imminent,  91. 
in  pneumonia,   101. 
Blood,  velocity  of  flow,  34,  35. 

volume  of,  relation  to  blood  pressure,  34,  35. 
Blood  pressure,  abnormal,  38. 

age,  effect  of,  121. 

age,  readings  at  different  periods,  37, 

38. 
auscultatory,  sounds  and  phases,  11,  12, 

13. 
cases  of  value  in,  5. 
definition  of,  7. 


134  INDEX 

Blood  pressure,  diastolic,  measurement  of,  9,  10. 
divisions  of,  7. 
drugs  elevating,  57-60. 
drugs  lowering,  97-98. 
effect  of  aconite,  91,  98. 
effect  of  adrenalin,  58. 
effect  of  alcohol,  97. 
effect  of  atropine,  60. 
effect  of  caffein,  60. 
effect  of  camphor,  58. 
effect  of  chloral  hydrate,  98. 
effect  of  chloroform,  98. 
effect  of  cocaine,  58. 
effect  of  coffee,  60. 
effect  of  digitalis,  58. 
effect  of  ergot,  60. 
effect  of  iodides,  98.     ^ 
effect  of  nitrites,  98. 
effect  of  pituitary  extract,  60,  98. 
effect  of  saline  solution   (normal),  59. 
effect  of  strychnia,  59,  60. 
effect  of  tobacco,  60,  97. 
effect  of  thyroid  extract,  98. 
exercise,  effect  on, 

in  normal  eases,  41. 

in  myocarditis,  69-70. 
in  treatment  of,  87. 
factors  on  which  it  depends,  28,  29,  30. 
from  manipulation  during  operation,  116. 
high  and  maintained,  effect  of,  46. 
historical  review  of,  1-4. 
hypertension,  46-95. 
hypotension,  95-110. 

importance  of,  and  conditions  to  which 
it  applies,  4-7. 


INDEX  135 

Blood  pressure,  in  alcoholic  delirium,  105. 

in  anaemia,  96. 

in  anaesthesia.  111,  112. 

in  angina  pectoris,  50-57. 

in  angiosclerosis,  49,  50. 

in  aortic  regurgitation,  67. 

in  apoplexy,  72,  73. 

in  arteriosclerosis,  51-56. 

in  asphyxia,  45. 

in  autointoxication,  56,  57. 

in  bradycardia,  71. 

in  carcinoma  of  the  stomach,  with  vom- 
iting, 97. 

in  cardiac  arrhythmia,  71. 

in  cardiac  conditions   (acute),  96. 

in  cardiac  failure  and  asthma,  68-69. 

in  cardiac  hypertrophy    (chronic),  68. 

in  cardiac  valve  lesions,  other  than  aor- 
tic, 68. 

in  cataract,  64. 

in  cerebral  thrombosis,  72,  73. 

in  cerebrospinal  meningitis,  98. 

in  cholera,  96,  97. 

in  collapse,  108,  109. 

in  collapse,    premonitory    sign    of,    in 
operations,  114. 

in  concussion  of  brain,  73. 

in  diabetes,  57. 

in  diarrhoea,  96,  97. 

in  diphtheria,  99. 

in  diseases   with  marked  loss  of   fluid, 
96,  97. 

in  dysentery,  96,  97. 
in  eclampsia,  76,  79. 
in  edema,  45. 


136  INDEX 

Blood  pressure,  in  endocarditis  (acute),  71. 

in  epilepsy,  idiopathic,  60,  61. 

in  epilepsy,  Jacksonian,  72,  73. 

in  ex-ophthalmic  goiter,  61. 

in  eye  diseases,  61-67. 

in  fracture  of  the  skull   (base),  72,  73. 

in  fracture  of  the  skull  (depressed),  72. 
73. 

in  glaucoma,  66. 

in  gout,  67. 

in  haemorrhage,  extensive,  98. 

in  haemorrhage,  intracranial,  72,  73. 

in  hysteria,  106. 

in  infectious  diseases,  acute,  98,  99. 

in  infections  of  children,  acute,  105. 

in  insomnia,  106. 

in  intestinal  obstruction  (with  vomit- 
ing), 97. 

in  life  insurance,  117-123. 

in  mania,  acute,  106. 

in  melancholia,  106. 

in  myocarditis,  69. 

in  nephritis,  73-76. 

in  nephritis,  acute,  75,  76. 

in  nephritis,  chronic  interstitial,  74,  75. 

in  nephritis,  chronic  parenchymatous,  75. 

in  neuralgia,  trifacial,  107. 

in  neurasthenia,  106. 

in  operations,  treatment  of,  115. 

in  paresis,  general,  106. 

in  scarlet  fever  and  nephritis  compli- 
cating, 102. 

in  scarlatinal  nephritis,  76. 

in  obstetrics,  76-79. 

in  operative  surgery,  value  of,  114. 


INDEX  137 

Blood  pressure,  in  pericarditis,  96. 

in  peritoneal  effusion,  113. 

in  peritonitis,  with  vomiting,  97. 

in  plumbism,  79,  80. 

in  phthisis,   107. 

in  phthisis,  chronic,  96. 

in  pleural  effusion,  113. 

in  pneumonia,  100,  101. 

in  pregnancy,  76-79. 

in  pregnancy,  toxaemia  of  the  first  half, 
with  pernicious  vomiting,  77. 

in  pregnancy,  toxaemia  of  the  last  half, 
77. 

in  retinal  haemorrhage,  66. 

in  rheumatism,  acute  articular,  102. 

in  shock,  108,  109. 

in  shock,  post-operative,  113. 

in  spasm  of  the  retinal  vessels,  63. 

in  spinal  anaesthesia,  112. 

in       surgery,       operative       procedures, 
112-116. 

in  syphilis,  acute,  109. 

in  syphilis,  chronic.     See  arteriosclero- 
sis, 49,  50. 

in  tabes  dorsalis,  109,  110. 

in  tumors,  cerebral,  rapid  growing,   72, 
73. 

in  typhoid  fever,  102-104. 

in  uraemia,  76. 

in  wasting  diseases,  chronic,  96. 

instruments,    aneroid,    spring- diaphragm 
or  dial,  discussion  of,  23-26. 

Benedick  air-water,  23. 
V.  Bosch,  2. 
Brown,  21. 


138  INDEX 

Blood  pressure,  choice  of,  17,  18. 

classification  of,  18,  19. 
Cook,    description    of,    and 

cut,  19,  20. 
Erlanger,  27. 
Taught,  21. 
Hertz,  23. 
Janeway,    description    and 

cut,  21,  22. 
Martin,  21. 
Mercer,  21. 

mercurial,  18-23,  26,  27. 
Nicholson,    description  and 

cut,  26,  27. 
Pachon,  27. 
Eiva  Eocci,  2,  3,  19. 
Eoger's  simplex,  23. 
Sahli,  21. 
Sands,  19. 
Stanton,     description     and 

cut,  19,  20. 
Uskoff,  27. 
low  limit,  38,  89. 

maintenance  of,  mechanics,  29,  30. 
methods  of  measuring,  8. 
normal  readings,  adults  and  children,  37. 
physiologic  variation,  due  to  altitude,  42, 

43,  44. 
physiologic  variation,  due  to  breathing, 

41. 
physiologic  variation,  due  to  exercise,  41, 

42. 
physiologic  variation,  due  to  location  of 

cuff,  40. 
physiologic  variation,  due  to  meals,  41. 


INDEX  139 

Blood  pressure,  physiologic    variation,    due    to    nervous 

and  mental  stimuli,  42. 
physiologic  variation,  due  to  position  of 

patient,  40,  41. 
physiologic  variation,  due  to  time  taken 

in  making  readings,  44. 
physiologic   variation,   summary  of,   44, 

45. 
routine  determination  of,  and  its  value, 

36,  37,  48. 
routine  observation  of,  and  importance 

in  surgical  shock,  113-116. 
systolic,  measurement  of,  8,  9. 
value  of,  in  physical  diagnosis,  6. 
variation  in,  due  to  asphyxia,  45* 
variation  in,  due  to  CBdema,  45. 
Bosch,  v.,  instrument  of,  2. 
Bradycardia,  blood  pressure  in,  71. 

Caffein,  effect  on  blood  pressure,  60. 
Camphor,  effect  on  blood  pressure,  58. 

in  pneumonia,  101. 
Cancer,  blood  pressure  in,  96. 
hypotension  in,  96. 

of  stomach,  with  profuse  vomiting,  97. 
Cardiac  arrhythmia,  functional  or  orgruic,  71,  72. 

hypertension  in,  72. 
Cardiac  conditions  (acute),  blood  pressure  in,  96. 

hypotension  in,  96. 
Cardiac    failure    and    asthma,    blood    pressure    in,    58, 

59. 
Cardiac  failure,  in  nephritis,  75. 

in  pneumonia,  101. 
Cardiac  hypertrophy,  blood  pressure  in,  68. 

result  of  hypertension,  46. 


140  INDEX 

Cataract,  blood  pressure  in,  64,  65. 

blood      pressure      determination     in,      before 

operation,  64. 
prevention  of  post-operative  hgemorrhage  in,  64. 
Cereal  diet  in  treatment  of  hypertension,  90. 
Cerebral  concussion,  diagnosis  of,  73. 
Cerebral  thrombosis,  blood-pressure  readings  in,  73. 

hypertension  compensatory  in,  73. 
treatment  of,  73. 
Cerebrospinal  meningitis  (epidemic),  98. 
Children,  blood-pressure  readings  in,  38. 
Chloral  hydrate,  hypotension  from,  98. 

in  angina  pectoris,  88,  89. 
in  treatment  of  hypertension,  89. 
in  psychic  hypertension,  89. 
Chloroform,  effect  on  blood  pressure,  111. 

hypotension  from,  98. 
Cholera,  hypotension  in,  and  cause  of,  97. 

value  of  blood-pressure  determinations  in,  97. 
Cocaine,  effect  on  blood  pressure,  58. 

hypotension  from,  and  maintenance  of,  109. 
in  collapse,  109. 
in  shock,  109. 

in  shock,  prophylactic  treatment  of,  113. 
in  spinal  anaesthesia,  effect  on  blood  pressure, 
112. 
Coffee,  effect  on  blood  pressure,  60. 
Collapse,  adrenalin  intravenously  in,  109. 
blood  pressure  in,  108,  109. 
cocaine  in,  109. 

hypotension  in,  cause  of,  108,  109. 
in  ansesthesia,  112. 
premonitory  signs  of,  in   surgical  conditions, 

114. 
treatment  of,  109. 


INDEX  141 

Concussion  of  the  brain,  differential  diagnosis  of,  73. 
Cook,  H.  W.,  blood-pressure  instrument  of,  19,  20. 

Diarrhoea,  hypotension  in,  and  cause  of,  97. 

value  of  blood-pressure  determinations  in,  97. 
Diastolic  pressure,  definition  of,  7. 

discussion  of,  31-36. 
in  aortic  regurgitation,  67,  68. 
in  life  insurance,  123. 
measurement  of,  9,  10. 
normal  reading,  37. 
relation  of  blood  vessels  to,  52. 
relation  to  pulse  rate,  32. 
value  of,  31,  32. 
Diet,  in  the  treatment  of  hypertension,  81,  82. 
Digitalis,  dosage  and  effect  on  blood  pressure,  104. 
effect  on  blood  pressure,  53. 
in  collapse,  109. 
in  pneumonia,  101. 
in  shock,  109. 

in  senile  hearts,  with  hypertension,  90. 
in  typhoid  fever,  104. 
in  the  treatment  of  hypertension,  90. 
value  in  raising  blood  pressure,  58. 
Diphtheria,  hypotension  in,  99. 

value  of  blood-pressure  readings  in,  99. 
Drugs,  causing  hypertension,  57-60. 

causing  hypotension,  97,  98. 
Dysentery,  hypotension  in,  and  cause  of,  97. 

value  of  blood-pressure  determinations  in,  97. 

Eclampsia,  blood  pressure  in,  76-79. 
Edema,  effect  on  blood  pressure,  45. 
Electricity  in,  treatment  of  hypertension,  92,  93. 
Electric-light  baths,  in  the  treatment  of  hypertension,  93. 


142  INDEX 

Endocarditis  (acute),  hypotension  in,  71. 
Erlanger,  blood-pressure  instrument  of,  27. 
Epilepsy,  idiopathic,  differential  diagnosis  of,  61. 

Jacksonian,  blood-pressure  readings  in,  72,  73. 
Ergot,  effect  on  blood  pressure,  60. 
Erythrol  tetranitrate,  in  hypertension,  dose,  etc.,  92. 
Ether,  effect  on  blood  pressure.  111. 
Exercise,  effect  on  blood  pressure  in  myocarditis,  69,  70. 

effect  on  blood  pressure  in  normal  cases,  41. 

in  treatment  of  hypertension,  87. 

in  treatment  of  hypotension,  110. 
Ex-ophthalmie  goiter,  blood  pressure  in,  61. 
Eye  diseases,  blood  pressure  in,  61-67. 

routine  blood-pressure  readings, 
importance  of,  61,  62. 

Faught,  blood  pressure  instrument  of,  21. 
Females,  blood-pressure  readings  in,  38. 

Gibson's  rule,  in  pneumonia,  100. 

Crlaucoma,  hypertension  in,  66. 

Graupner  test,  for  myocarditis,  67-69. 

Gout,  hypertension  in,  67. 

Gymnastics,  in  the  treatment  of  hypertension,  94. 

Haemorrhage,  extensive,  hypotension  from,  98. 

in  typhoid  fever,  103. 

intracranial,  blood  pressure  in,  72,  73. 

intracranial,   differential  diagnosis  in,  73. 

intracranial,  hypertension  in,  73. 

intracranial  treatment  in,  73. 

retinal,  blood  pressure  in,  66. 

treatment  of,  normal  saline  solution,  59. 
Head  injuries,  differential  diagnosis  in,  73. 
Headaches,  in  autointoxication,  56. 


INDEX  143 

Heart,  brown  atrophy,  the  cause  of  hypotension,  96. 
Heart    diseases,  blood  pressure  in,  67-72. 

disease   (acute),  hypotension  in,  96. 

effect  of  altitude  in,  43. 

relation   of   each   contraction  to  the  blood-presh 

sure  reading,  14-16. 
strength  of,  relation  to  blood  pressure,  28. 
weakness,  determination  of,  33. 
Hertz,  blood-pressure  instrument  of,  23. 
Hot  packs  in  alcoholic  delirium,  105. 
Hydrotheraphy,  in  the  treatment  of  hypotension,  110. 
Hygiene  (general)  in  the  treatment  of  hypotension,  110, 
Hypertension,  46-95. 

cardiac  hypertrophy  in,  46. 

causes  of,  46,  47. 

compensatory,  80. 

diseases  with,  49-80. 

drugs  causing,  57-60. 

early  diagnosis  of,  importance  of,  47. 

exercise  in  the  treatment  of,  87. 

from  alcohol,  97. 

from  ether,  111. 

from  tobacco,  97. 

general  consideration  of,  46-48. 

in  angina  pectoris,  50,  51. 

in  angiosclerosis,  49,  50. 

in  aortic  regurgitation,  67,  68. 

in  apoplexy,  72,  73. 

in  arteriosclerosis,  51-56. 

in  asphyxia,  54. 

in  autointoxication,  56,  57. 

in  bradycardia,  71. 

in  cardiac  arrhythmia,  71. 

in  cardiac  failure  and  asthma,  68,  69. 

in  cardiac  hypertrophy,   68. 


144  INDEX 

Hypertension,  in  cataract,  64,  65. 

in  cerebral  thrombosis,  72,  73. 

in  eclampsia,    76-79. 

in  edema,  45. 

in  epilepsy,  idiopathic,  60,  61. 

in  epilepsy,  Jacksonian,  72,  73. 

in  ex-ophthalmic  goiter,  61. 

in  eye  diseases,  61-67. 

in  glaucoma,  66. 

in  gout,  67. 

in  haemorrhage   (extensive),  72,  73. 

in  increased  intracranial  tension,  72,  73. 

in  myocarditis,  71. 

in  nephritis,  chronic  interstitial,  74,  75. 

in  nephritis,  chronic  interstitial,  in  rela- 
tion to  the  eye,  65. 

in  obstetrics,  76-79. 

in  peritoneal  effusion,  113. 

in  phthisis,  107,  108. 

in  pleural  effusion,  113. 

in  plumbism,  79,  80. 

in  retinal  haemorrhage,  66. 

in  scarlatinal  nephritis,  76,  102. 

in  spasm  of  the  retinal  vessels,  63,  64. 

in  senile  hearts,  90. 

in  skull,  fracture  of,  base,  72,  73. 

in  skull,  fracture  of,  depressed,  72,  73. 

in  typhoid  fever,  perforation  in,  103,  104. 

in  tumors,  cerebral,  rapid-growing  cere- 
bral, 72,  73. 

in  uraemia,  76. 

inability  to  determine  by  palpation,  72. 

increasing  frequency  of,  due  to,  46,  47. 

primary,  47. 

psychic,  treatment  of,  89. 


INDEX  145 

Hypertension,  relation  to  pulse  pressure,  33. 

routine    blood-pressure    determination    to 

detect,  48. 
treatment  of,  80-94. 
treatment  of,  aconite  in,  91. 
treatment  of,  alkali  by  rectum  in,  84. 
treatment  of,  bathing  in,  87. 
treatment  of,  hot  baths  in,  90. 
treatment  of,  baths,  oxygen   in,    93. 
treatment  of,  bromides  in,  89. 
treatment  of,  cereal  diet  in,  90. 
treatment  of,  chloral  hydrate  in,  88,  89. 
treatment  of,  diet  in,  81,  82. 
treatment  of,  digitalis  in,  90. 
treatment  of,  electricity  in,   92,  93. 
treatment  of,  exercise  in,  87. 
treatment  of,  factors  involved  in,  82,  83. 
treatment  of,  immediate,  83,  84. 
treatment  of,  in  increased  intra-abdominal 
pressure,  85,   86. 

treatment  of  iodides  in,  88,  89. 

treatment  of,  laxatives  in,  and  the  time  to 
be  given,  84. 

treatment  of,  mercury  salts  in,  90,  91. 

treatment  of,  nitroglycerine  in,  91-93. 

treatment  of,  obesity   in    relation  to,    80, 
81. 

treatment  of,  prophylaxis,  80,  81. 

treatment  of,  rest  after  meals,  89. 

treatment  of,  rest    (absolute)    with    milk 
diet  and  massage,  90. 

treatment  of,  salt  intake  in,  90. 

treatment  of,  sleep  in,  87. 

treatment  of,  thyroid  extract  in,  93. 

treatment  of,  venesection  ia,  90,  91. 


146  INDEX 

Hypertension,  treatment   of,   vasodilators  in,  92,   93. 

treatment  of,  wet  pack  in  (neurasthenia), 
94. 

vascular  changes  from,  46. 

with   proportionately   high   diastolic  pres- 
sure relation  to  circulation,  33. 
Hypotension,  95-110. 

caused  by,  95,  96. 

definition  of,  95. 

general  consideration  of,  95,  96. 

from  alcohol,  97. 

from  cerebrospinal  meningitis,  98. 

from  chloroform,  111. 

from  syphilis  (acute),  109. 

from  tobacco,  97. 

importance  of,  95. 

in  alcoholic  delirium,  105. 

in  ansEsthesia,  treatment  of,  112. 

in  carcinoma  of  the  stomach,  97. 

in  cardiac  conditions  (acute),  96. 

in  cholera,  96,  97. 

in  collapse,  108,  109. 

in  diphtheria,  99. 

in  dysentery,  96,  97. 

in  diarrhoea,  96,  97. 

in  diseases  with  marked  loss  of  fluid,  96, 
97. 

in  endocarditis  (acute),  71. 

in  haemorrhage,  extensive,  98. 

in  infectious  diseases  (acute),  98,  99. 

in  infections  of  children   (acute),  105. 

in  insomnia,   106. 

in  intestinal  obstruction,  with  vomiting,  97. 

in  life  insurance,  123. 

in  melancholia,  106. 


INDEX  147 

Hypotension,  in  neuralgia,  trifacial,  107. 

in  paresis,  general,  106. 

in  mania  (acute),  106. 

in  operations,  treatment  of,  115,  116. 

in  pericarditis,  96. 

in  peritonitis   (vomiting),  97. 

in  pneumonia,  100,  101. 

in  rheumatism  (acute  articular),  102. 

in  scarlet  fever,  102. 

in  shock,  108,  109. 

in  spinal  anaesthesia,  112. 

in  typhoid  fever,  102,  103. 

in  typhoid  fever,  in  hasmorrhage  in,  103, 

in  wasting  diseases    (chronic),  96. 

relation  to  cardiac  weakness,  33. 

relation  to  dilated  arteries,  33. 

treatment  of,  exercise  in,  110. 

treatment  of,  hydrotheraphy  in,  110. 

treatment  of,  laxatives  in,  110. 

treatment  of,  massage  in,  110. 

vasomotor  tension  in,  95,  96. 
Hysteria,  blood  pressure  in,  106. 

Indicanuria,  in  autointoxication,  57. 

in  the  treatment  of  hypertension,  83. 
Inertia  of  mercury,  relation  to  accuracy  of  readings,  14, 

15. 
Infectious  diseases  (acute),  hypotension  in,  98,  99. 
Infections  of  children  (acute),  blood  pressure  low  limit 

in,  105. 
blood  pressure  in  treat- 
ment of,  105. 
prognosis  in,  105. 
Insomnia,  hypertension  in,  106. 
hypotension  in,  106. 


148  INDEX 

Insonmia,  treatment  of,  106. 

vasodilators  in,  106. 
Intestinal  obstruction  (with  vomiting),  hypertension  in, 

97. 
value  of  blood-pressure  determina- 
tion in,  97. 
Intra-abdominal  tension    (increased),  treatment  of,  85, 

86. 
causes  of,  85. 
hypertension  in,  85. 
Intracranial  tension,  increased,  hypertension  in,  72,  73. 
Iodides,  hypotension  from,  98. 

in  arteriosclerosis,  89,  91. 

in  senile  hearts  with  hypertension,  90. 

in  syphilitic   arteriosclerosis,   treatment  of,   89. 

in  the  treatment  of  hypertension,   88-91. 

in  the  treatment  of  hypotension,  88,  89. 

Janeway,  T.  H.,  blood-pressure  instrument  of,  21,  22. 

Korotkoff,  auscultation  method  of,  8. 
Kymographion,  the,  1. 

Laxatives,  in  the  treatment  of  hypertension,  84. 
in  the  treatment  of  hypotension,    110. 
Life  insurance,  age  in  effect  on  blood-pressure  readings, 
121,  122. 
blood  pressure  in,  117-123. 
blood-pressure   readings  factors  to  con- 
sider in  obtaining,  119,  120. 
blood-pressure  readings  limits  of,  1?2. 
blood-pressure  statistics  in,  117,  118. 
diastolic    pressure,    the    importance    of, 

123. 
diseases  to  consider,  123, 


INDEX  149 

Life  insurance,  hypotension  in,  123. 

myocarditis,  functional  test  of,  123. 

pulse   pressure  in,  importance  of   deter- 
mining, 123. 

sphygmomanometer,  value  of,  118. 
Ludwig,  instrument  of,  kymographion,  1. 

Mania  (acute),  hypotension  in,  106. 
Marey,  blood-pressure  instrument  of,  1. 
Martin,  blood-pressure  instrument  of,  21. 
Massage,  in  the  treatment  of  hypertension,  94. 
in  the  treatment  of  hypotension,    110. 
Meals,  influence  on  blood  pressure,  42. 
Mean  pressure,  definition  of,  7. 
Melancholia,  hypertension  in,  106. 

treatment  of,  106. 
Meningitis,  blood  pressure  in,  98. 
Mental  stimuli,  effect  on  blood  pressure,  42. 
Mercer,  blood-pressure  instrument  of,  21. 
Mercurial,  blood-pressure  instruments,  18-23,  26,  27. 
Mercury,  inertia   of   and   relation  to   accuracy   of  read- 
ings, 14,  15. 
oscillation  of  the  column,  significance  of,  14, 

15. 
salts  of,  in  the  treatment  of  hypertension,  90, 

91. 
salts  of,  in  the  treatment  of  toxic  hypertension, 
90,  91. 
Myocarditis,  blood  pressure  in,  69-71. 
functional  test  of,  69,  70. 
sequel  to  arteriosclerosis,  55,  56. 

Nephritis,  73-76. 

acute,  blood  pressure  in,  75,  76. 
cardiac  failure  in,  75. 


150  INDEX 

Nephritis,  chronic  interstitial,  in  relation  to  the  eye,  65. 
chronic  interstitial,  readings  in,  74,  75. 
chronic  interstitial,  pulse  pressure  in,  74,  75. 
chronic  parenchymatous,    blood    pressure    in, 

74,  75. 
scarlatinal,  hypertension  from,  76. 
Nervous  stimuli,  effect  on  blood  pressure,  42. 
Neuralgia,  trifacial,  hypertension  in,  107. 
Neurasthenia,  blood  pressure  in,  106. 

treatment  of,  wet  pack  in,  93. 
Neurological  conditions,  105-107. 
Nicholson,  P.,  blood-pressure  instrument  of,  26,  27. 
Nitrites,  hypotension  from,  98. 

Nitrites  in  the  treatment  of  senile  hearts  with  hyperten- 
sion, 90. 
Nitrites,  permanency  and  symptoms  caused  by,  92,  93. 
Nitroglycerine,  in  hypertension,  dose,  duration  and  tol- 
erance, 92,  93. 
Nitrous  oxide,  effect  on  blood  pressure.  111. 

Obesity,  treatment  of,  when  associated  with  hypertension, 
85,  86. 

Oscillation  of  the  mercury  column,  in  relation  to  ac- 
curacy of  readings,  14,  15. 

Obstetrics,  blood  pressure  in,  76-79. 

Oxygen  baths  in  the  treatment  of  hypertension,  93. 

Pachon,  blood-pressure  instrument  of,  27. 

Pain,  effect  on  blood  pressure,  42. 

Palpation  method  of  blood  pressure,  8,  9. 

Paresis,  general  blood  pressure  in,  106. 

Psychic  hypertension,  treatment  of,  oxygen  baths  in,  93. 

Pericarditis,  blood  pressure  in,  96. 

hypotension  in,  96. 
Peripheral  resistance,  relation  to  blood  pressure,  28. 


INDEX  151 

Peritoneal  effusion,  blood  pressure  in  the  aspiration  of, 

113. 
hypertension  from,  113. 
Peritonitis,    (with  vomiting),  hypotension  in,  97.^ 

value  of  blood-pressure  determination  in,  97. 
Phthisis,   blood-pressure  readings  in,  107. 

blood-pressure,   value   of,  in  the   diagnosis  of, 

107,  108. 
blood-pressure    variations    in,    significance    of, 

107,  108. 

continued  hypotension  in,  108. 
effect  of  altitude  in,  44. 
chronic,  blood  pressure  in,  96. 
hypotension,    significance    of,    in    prophylaxis, 
108. 
Pituitary  extract,  danger  of  use  of,  60. 

effect  on  blood  pressure,  60. 
hypotension  from,  98. 
Pleural  effusion,  blood  pressure  in  the  aspiration  of,  113. 

hypertension  from,  113. 
Plumbism,  blood  pressure  in,  79,  80. 
Pneumatic  cuff  location  of  effect  on  blood  pressure,  40. 
Pneumonia,  adrenalin  in,  101. 

blood  pressure  in,  100-102. 

blood  pressure  in  the  treatment  of,  101,  102. 

blood-pressure  variations  in,  100,  101. 

camphor  in,  101. 

cardiac  failure  in,  101. 

cardiac  or  vascular  failure,  diagnosis  of,  101. 

digitalis  in,  101. 

Gibson's  rule  in,  100. 

drugs  in,  101. 

hypertension  and  hypotension  in,  causes  of, 

100,   101. 
vasomotor  paralysis  in,  100,  101. 


152  INDEX 

Pneumonia,  venesection  in,  100,  101. 

Poiselli,  blood-pressure  instrument  of,  1. 

Pneumatic  cuff,  width  of,  3,  17. 

Position  of  patient,  influence  on  blood  pressure,  40,  41. 

Pregnancy,  blood  pressure  in,  76-79. 

normal  readings  in,  76,  77. 
pernicious  vomiting,  blood  pressure  in,  77. 
Psychic  hypertension,  treatment  of,  89. 
V.  Ptoin,  blood-pressure  instrument  of,  2. 
Pulsations  of  the  heart,  relation  to  blood-pressure  read- 
ings, 14-16. 
Pulse  pressure,  definition  of,  7. 

discussion  of,  31-36. 

in  arteriosclerosis,  with  myocarditis,  55, 
56. 

in  aortic  regurgitation,  67,  68. 

in  chronic  interstitial  nephritis,  74,  75. 

in  pneumonia,  importance  of,  101. 

large,  relation  to  arterial  dilatation,  33. 

normal  readings  in,  31. 

per  cent,  of  systolic  pressure,  31. 

relation  of  blood  vessels  to,  32. 

relation  of  strength  of  heart  to,  33. 

relation  to  pulse  rate,  32. 

relation  to  velocity  of  blood,  34. 

small,  meaning  of,  34. 

small,  relation  to  heart  weakness,  33. 

the  head  pressure,  30. 

value  of,  33-35. 

with    high    systolic    and    proportionate 
diastolic  pressure,  33. 
Pulse  rate,  relation  to  pulse  pressure,  32. 

Best,  in  the  treatment  of  hypertension,  90. 

in  the  treatment  of  psychic  hypertension,   89. 


INDEX  153 

Retinal  haemorrhage,  hypertension  the  cause  of,  66. 
Betinal  vessels,  spasm  of,  blood  pressure  in,  63. 

symptoms  and  treatment  of,  63,  64. 
Reservoir    type,    blood-pressure   instruments,    18-21,    26, 

27. 
Rheumatism   (acute  articular),  blood  pressure  in,  102. 
Riva  Rocci,  blood-pressure  instrument  of,  2,  3,  19. 
Roger's  simplex,  blood-pressure  instrument,  23. 

Sahli,  blood-pressure  instrument  of,  21. 
Saline  solution  (normal),  effect    on    blood    pressure    in 

haemorrhage,  59. 
effect    on    blood    pressure    in 

shock,  59. 
intravenously  in  collapse,  109. 
intravenousy  in  shock,  109. 
in   treatment   of  and  preven- 
tion of  shock,  115,  116. 
Salt,  in  the  treatment  of  hypertension,  90. 
Sands,  blood-pressure  instrument,  19. 
Scarlet  fever,  blood  pressure  in,  102. 
hypertension  in,  102. 
hypotension  in,  102. 
nephritis  in   (hypertension),  76. 
Serous  effusions,  blood  pressure  in,  113. 
Shock,  adrenalin  intravenously  in,  109. 
blood  pressure  in,  108,  109. 
cocaine  in,  109. 

hypotension  in,  cause  of,  108,  109. 
in  anaesthesia,  112. 
normal  saline  solution  in,  59. 
prevention  of,  cocaine  for,  113. 
prophylaxis  in  operative  cases,  cocaine  in,  113. 
surgical  blood  pressure  in  the  diagnosis  of,  113. 
treatment  of,  109. 


154  INDEX 

Shock,  treatment  of,  in  operative  cases,  use  of  saline  so- 
lution, 115,  116. 
Skull,  depressed  fracture  of,  blood  pressure  in,  73. 

depressed  fracture  of,  differential     diagnosis    of, 

73. 
depressed  fracture  of,  hypertension  in,  and  cause 

of,  73. 
depressed  fracture  of,  treatment  of,  73. 
fracture  of  the  base,  blood  pressure  in,  73. 

differential  diagnosis  in,  73. 
hypertension  in,   and  cause 

of,  73. 
treatment  of,  73. 
Sleep,  in  the  treatment  of  hypertension,  87. 

influence  on  blood  pressure,  41. 
Sodium  nitrite,  in  hypertension,  dose,  duration,  and  tol- 
erance, 92. 
Sphygmomanometer,  aneroid,  18,  23-26. 
V.  Bosch,  13. 
Bendick,  23. 
Brown,  21. 
choice  of,  17,  18. 
classification  of,  18,  19. 
Cook,  description  and  cut,  19,  20. 
dial,  18,  23-26. 
diaphragm,  18,  23-26. 
Erlanger,  27. 
Faught,  21. 
Hertz,  23. 

in  life  insurance,  118. 
in  surgery,  importance  in,  114-116. 
Janeway,   description  and  cut,   21- 

22. 
Martin,  21. 
Mercer,  21. 


INDEX  155 

Sphygmomanometer,  Nicholson,  description  and  cut,  26, 

27. 
Pachon,  27. 
Roger's  simplex,  23. 
Sahli,  21. 
Sands,  19. 

Stanton,  description  and  cut,  19,  20. 
U  tube,  discussion  of,  22. 
Stanton,  W.  H.,  blood-pressure  instrument  of,  19,  20. 
Strychnia,  dose  and  effect  on  blood  pressure,  104. 
dose  to  elevate  blood  pressure,  59,  60. 
effect  on  blood  pressure,  59,  60. 
duration  of  hypertension  from,  59,  60. 
in  collapse,  109. 
in  pneumonia,  101. 
in  shock,  109. 
in  typhoid  fever,  104. 
value  of,  to  elevate  blood  pressure,  59,  60. 
Sulphonal,  in  insomnia,  106. 

Surgery,  blood  pressure  in,  post-operative,  value  of,  113. 
blood-pressure    observations    before    operation, 

value  of,  113. 
operative,  blood  pressure  in,  112-116. 
operative,    blood-pressure    reading,    indicating 

need  for  active  interference,  115. 
routine  blood  pressure  in,  importance  of,  113- 

116. 
shock  in,  prophylaxis  of,  115. 
Syphilis,  blood  pressure  in,  109. 

hypotension  from,  in  acute,  109. 
Syphilitic  arteriosclerosis,  iodides  in  the  treatment  of,  89. 
Systolic  pressure,  abnormal  readings  in,  high  and  low, 
38,  39. 
definition  of,  7. 
high,  relation  to  pulse  pressure,  33. 


156  INDEX 

Systolic  pressure,  in  aortic  regurgitation,  67. 

indication  of  strength  of  the  cardiac 

contraction,  30, 
low,  relation  to  dilated  arteries,  33. 
low,  relation  to  weak  heart,  33. 
measurement  of,  8,  9. 
normal  readings  of,  37. 
relation    to    intraventricular   pressure, 

30. 

Tabes  dorsalis,  differential  diagnosis  of,   110. 

hypertension  in  gastric  crises,  109,  110. 
hypotension  in  lightning  pains   of,   109, 
110. 
Tea,  effect  on  blood  pressure,  60. 
Thyroid  extract,  hypotension  from,  98. 
Tobacco,  hypertension  from,  97. 
hypotension  from,  97. 
Toxaemia  of  pregnancy,  of  the  first  half,  with  vomiting, 

77. 
of  the  last  half,  77. 
treatment  of,  78,  79. 
Toxic  hypertension,  mercury  salts  in,  90,  91. 

treatment  of,  90,  91. 
Trional  in  insomnia,  106. 
Typhoid  fever,  alcohol  in  the  treatment  of,  104. 

baths  in,  and  their  effect  on  blood  pres- 
sure, 104. 
blood-pressure  readings  in,  102,  103. 
complications  in,  the  diagnosis  of,   103, 

104. 
digitalis  in,  104. 
haBmorrhage  in,  103. 
hypertension  following,  105. 
hypotension  in,  102,  103. 


INDEX  157 

Typhoid  fever,  perforation  in,  103,  104. 

routine  blood  pressure  in,  103. 

strychnia  in,  104. 
Tumors,  cerebral,  rapid  growing,  blood  pressure  in,  73. 

hypertension  in,  and  cause  of,  73. 
treatment  of,  73, 

Uraemia,  blood  pressure  in,  76. 

differential  diagnosis  from  epilepsy,  61. 
Uskoff,  blood-pressure  instrument  of,  27. 
U-tnbe  mercurial  blood-pressure  instruments,  21,  22. 

Vascular  wall,  elasticity  of,  in  relation  to  blood  pres- 
sure, 29. 
Vasodilators,  92. 

in  insomnia.  106. 

in  pneumonia,  101. 

summary  of  effect  in  hypertension,  92,  93. 
Vasomotor  paralysis  in  pneumonia,  100,  101. 
Velocity  of  the  blood,  determination  of,  34. 
Venesection,  in  hypertension,   apoplexy   imminent,    91. 

in  pneumonia,  101. 

in.  toxic  hypertension,  acute,  90,  91. 

in  treatment  of  hypertension,  90,  91. 
Viscosity  of  the  blood,  relation  to  blood  pressure,  29. 

Wasting  diseases  (chronic),  hypotension  in,  96. 
Wet  pack,  in  the  treatment  of  hypertension,  94. 
Worry,  effect  on  blood  pressure,  42. 


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